Fla. Admin. Code Ann. R. 69L-56.3012 - Electronic Notice of Denial and Rescinded Denial

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

On or before the compliance date established in the insurer's Primary Implementation Schedule set forth in paragraph 69L-56.301(3)(a), F.A.C., the insurer shall file the electronic form equivalent for the denial information otherwise reported on Form DFS-F2-DWC-12, adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C. The claim administrator shall send to the Division an Electronic Notice of Denial to report the reason for the denial of indemnity benefits for the following types of denial notices, and by the following time periods:

(1) Electronic Notice of Denial - Full (Both Indemnity and Medical Benefits Denied):

(a) If the entire compensability of the claim is initially denied and both indemnity and medical benefits will not be paid by the claim administrator, the claim administrator shall file the Electronic Notice of Denial by reporting the applicable Full Denial Reason Code(s) and Full Denial Effective Date on the same FROI MTC 04 (Denial) the claim administrator sends to the Division to report the Electronic First Report of Injury or Illness, in accordance with filing time periods in subsection 69L-56.301(2), F.A.C. The Denial Reason Narrative shall also be sent on the FROI MTC 04 (Denial) to supplement the Full Denial Reason Code(s).

(b) If the claim administrator initially accepts compensability but subsequently denies liability for the entire claim after having previously paid indemnity benefits and the Electronic First Report of Injury or Illness has already been filed with the Division, the claim administrator shall file the Electronic Notice of Denial by sending a SROI MTC 04 (Denial). The Electronic Notice of Denial will be considered timely filed with the Division if 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 claim administrator decided to deny benefits. The claim administrator shall report the applicable Full Denial Reason Code(s) and Full Denial Effective Date on the SROI MTC 04 (Denial). The Denial Reason Narrative shall also be sent on the SROI MTC 04 (Denial) to supplement the Denial Reason Code(s).

(c) In addition to filing the Electronic Notice of Denial with the Division, the claim administrator shall produce and mail a paper copy of Form DFS-F2-DWC-12, Notice of Denial, adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C., to the employer and employee, in accordance with the filing time period set out for Form DFS-F2-DWC-12 in Rule 69L-56.4012, F.A.C.

(2) Electronic Notice of Denial - Partial (Indemnity Only Benefits Denied):

(a) If all indemnity benefits are initially denied but some or all medical benefits will be provided, the claim administrator shall file the Electronic Notice of Denial by reporting Partial Denial Code "A" (Denying Indemnity in whole, but not Medical) or partial Denial Code "E" (Denying Indemnity in whole and Medical in part) on the same SROI MTC PD (Partial Denial) the claim administrator sends with FROI MTC 00 (Original) to report the Electronic First Report of Injury or Illness in accordance with the filing time periods in subsection 69L-56.301(2), F.A.C. The claim administrator shall also report the "Denial Reason Narrative" on the SROI MTC PD to explain the reason for the denial of indemnity benefits.

(b) If payment of a specific indemnity benefit(s) is denied in whole or part subsequent to the claim administrator's initial disposition of the claim and the Electronic First Report of Injury or Illness has already been filed with the Division, the claim administrator shall file the Electronic Notice of Denial by sending a SROI MTC PD (Partial Denial). The Electronic Notice of Denial will be considered timely filed with the Division if 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 claim administrator decided to deny benefits. The claim administrator shall report the applicable Partial Denial Code as follows: "A" (Denying Indemnity in Whole, but not Medical); "B" (Denying Indemnity in part, but not Medical); "E" (Denying Indemnity in whole and Medical in part); or "G" (Denying both Indemnity and Medical in part). The claim administrator shall also report the "Denial Reason Narrative" on the SROI MTC PD to explain the reason for the denial of indemnity benefits.

(c) In addition to filing the Electronic Notice of Denial with the Division, the claim administrator shall produce and mail a paper copy of Form DFS-F2-DWC-12, Notice of Denial, adopted in Rules 69L-56.4012 and 69L-3.025 ,F.A.C., to the employer and employee, in accordance with the filing time period set out for Form DFS-F2-DWC-12 in Rule 69L-56.4012, F.A.C.

(3) Electronic Notice of Denial - Medical Only Case that becomes a Total or Partial (Indemnity Only) Denial:

(a) If a case is initially determined to be a compensable Medical Only Case and the claim administrator subsequent to its initial disposition denies both medical and indemnity benefits, i.e., Full/Total Denial, the claim administrator shall file an Electronic Notice of Denial with the Division by reporting the applicable Full Denial Reason Code(s), Full Denial Effective Date, and Denial Reason Narrative on the same FROI MTC 04 (Total Denial) the claim administrator sends to report the Electronic First Report of Injury or Illness, in accordance with the filing time period in subsection 69L-56.301(2), F.A.C.

(b) If a case is initially determined to be a compensable Medical Only Case and the claim administrator subsequent to its initial disposition denies indemnity benefits in whole but some or all medical benefits will be provided, i.e., Partial (Indemnity Only) Denial, the claim administrator shall file an Electronic Notice of Denial with the Division by reporting the applicable Partial Denial Reason Code(s) and Denial Reason Narrative on the same SROI MTC PD (Partial Denial) the claim administrator sends with the FROI MTC 00 (Original) to report the Electronic First Report of Injury or Illness, in accordance with the filing time periods in subsection 69L-56.301(2), F.A.C.

(4) If the claim administrator is invoking the "120 day rule" allowed in section 440.192(8), F.S., when initiating payment without prejudice to its right to subsequently deny benefits, it may send the Agreement to Compensate Code "W" (Without Liability) on the same SROI MTC IP (Initial Payment) being sent to report the Electronic First Report of Injury or Illness.

(5) The claim administrator shall not file an Electronic Notice of Denial with the Division if it is denying payment of a medical benefit only. However, the claim administrator shall provide Form DFS-F2-DWC-12, Notice of Denial, adopted in Rules 69L-56.4012 and 69L-3.025, F.A.C., to the employee, employer, and the party(s) requesting payment or authorization of a medical benefit.

(6) Electronic Notice of Rescinded Denial:

(a) Rescission of a Full Denial. If the claim administrator denied the claim in its entirety, either initially by sending an Electronic First Report of Injury or Illness FROI MTC 04 (Denial) or subsequent to its initial disposition by sending an Electronic Notice of Denial SROI MTC 04 (Denial), or if the claim administrator acquired a denied claim for which a First Report of Injury or Illness is already on file with the Division but subsequently accepts compensability of the claim, the claim administrator shall file an Electronic Notice of Rescinded Denial with the Division to report the change in disposition of the claim. The Electronic Notice of Rescinded Denial will be considered timely filed if it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before the 14 days after the date the denial was rescinded. The claim administrator shall also notify the employee and employer about the decision to rescind the full denial by sending to the employee and employer, Form DFS-F2-DWC-12, Notice of Denial, pursuant to Rules 69L-56.4012 and 69L-3.025 , F.A.C., or an explanatory letter. The Electronic Notice of Rescinded Denial shall be represented by sending a SROI MTC as follows:

1. The Electronic Notice of Rescinded Denial reporting payment of indemnity benefits shall be represented by sending SROI MTC IP (Initial Payment); SROI MTC AP (Acquired/Payment) for an acquired claim; SROI MTC PY (Payment Report) reporting a lump sum payment or settlement of indemnity benefits; SROI MTC RB (Reinstatement of Benefits) to report reinstatement of indemnity benefits that were paid by the claim administrator prior to the denial. The claim administrator shall report the "Denial Rescission Date", the date payment of indemnity benefits was mailed, and the type of indemnity benefits paid on the SROI MTC IP, AP, PY, or RB.

2. The Electronic Notice of Rescinded Denial reporting acceptance of a compensable death case where there are no known dependants shall be represented by sending SROI MTC CD (Compensable Death, No Dependents/Payees). The claim administrator shall report the "Denial Rescission Date" on the SROI MTC CD.

3. The Electronic Notice of Rescinded Denial reporting acceptance of a compensable volunteer shall be represented by sending SROI MTC VE (Volunteer). The claim administrator shall report the "Denial Rescission Date" on the SROI MTC VE.

4. The Electronic Notice of Rescinded Denial reporting reinstatement of indemnity benefits by the employer following a denial of indemnity benefits previously paid by the employer shall be represented by sending SROI MTC ER (Employer Reinstatement). The claim administrator shall report the "Denial Rescission Date" on the SROI MTC ER.

5. The Electronic Notice of Rescinded Denial reporting acceptance of compensability where indemnity or medical benefits will be denied in whole or in part, shall be represented by sending SROI MTC PD (Partial (Indemnity Only) Denial). The claim administrator shall report the "Denial Rescission Date" on the SROI MTC PD.

(b) Rescission of a Partial (Indemnity Only) Denial. If the claim administrator initially denied payment of indemnity benefits only and filed an Electronic First Report of Injury or Illness FROI 00 (Original) and SROI MTC PD (Partial Denial) with the Division, or the claim administrator acquired a Partial Denial claim for which a First Report of Injury or Illness is already on file with the Division and the claim administrator subsequently pays indemnity benefits, the claim administrator shall file an Electronic Notice of Rescinded Denial with the Division to report a change in disposition of the claim. The Electronic Notice of Rescinded Denial will be considered timely filed if it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before the 14 days after the date the denial was rescinded. The claim administrator shall also notify the employee and employer about the decision to rescind the Partial (Indemnity Only) Denial by sending to the employee and employer, Form DFS-F2-DWC-12, Notice of Denial, pursuant to Rules 69L-56.4012 and 69L-3.025, F.A.C., or explanatory letter. The Electronic Notice of Rescinded Denial shall be represented by sending a SROI MTC as follows:

1. The Electronic Notice of Rescinded Denial reporting payment of indemnity benefits shall be represented by sending SROI MTC IP (Initial Payment), or SROI MTC AP (Acquired/Payment) for an acquired claim. The Electronic Notice of Rescinded Denial reporting a lump sum payment or settlement of indemnity benefits shall be represented by sending SROI MTC PY (Payment Report). The claim administrator shall include the "Denial Rescission Date," the date the initial payment of indemnity benefits was mailed, and the type of indemnity benefits paid on the SROI MTC IP, AP, or PY.

4. The Electronic Notice of Rescinded Denial reporting reinstatement of indemnity benefits by the employer following a denial of indemnity benefits previously paid by the employer, shall be represented by sending SROI MTC ER (Employer Reinstatement). The claim administrator shall report the "Denial Rescission Date" on the SROI MTC ER.

(c) Rescission of Partial (Indemnity Only) Denial After Payment. If the claim administrator initially paid indemnity benefits and subsequently denied payment of indemnity benefits only and filed an Electronic Notice of Denial SROI MTC PD (Partial Denial) with the Division and elects to pay indemnity benefits again, or if the claim administrator acquired a claim for which indemnity benefits were previously paid and subsequently denied and the acquiring claim administrator subsequently pays indemnity benefits, the claim administrator shall file an Electronic Notice of Rescinded Denial with the Division to report a change in disposition of the claim. The Electronic Notice of Rescinded Denial will be considered timely filed if it is received by the Division and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted) on or before the 14 days after the date the denial was rescinded. The claim administrator shall also notify the employee and employer about the decision to rescind the partial denial by sending to the employee and employer, Form DFS-F2-DWC-12, Notice of Denial, pursuant to Rules 69L-56.4012 and 69L-3.025, F.A.C., or explanatory letter. The Electronic Notice of Rescinded Denial reporting reinstatement of indemnity benefits following a denial of indemnity benefits shall be represented by sending SROI MTC RB (Reinstatement of Benefits). The Electronic Notice of Rescinded Denial shall report the "Denial Rescission Date" and the type of indemnity benefits paid, on the SROI MTC RB.

(7) Any insurer failing to timely send the Electronic Notice of Denial in accordance with the filing time periods prescribed in this subsection shall be subject to administrative penalties assessable by the Division in accordance with the provisions of Rule 69L-24.007, F.A.C., and Section 440.525(4), F.S.

Notes

Fla. Admin. Code Ann. R. 69L-56.3012

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

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

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