(SROI MTC SA, FN 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-56.300(3)(a),
F.A.C., the insurer shall file the electronic form equivalent for claim cost
information otherwise reported on Form DFS-F2-DWC-13 adopted in Rules
69L-56.4013 and
69L-3.025, F.A.C. If payment has
been made for any of the Benefit Type (BT) Codes or Other Benefit Type (OBT)
Codes listed in subsections (1) and (2) of this section, the claim
administrator shall report on the Electronic Claim Cost Report, the cumulative
amount paid (i.e., Benefit Type Amount Paid, Other Benefit Type Amount) in
dollars and cents for each applicable BT Code, with the exception of BT Codes
reporting employer payment, and OBT Code. The claim administrator shall also
report the amount of weeks (i.e., Benefit Type Claim Weeks) and/or days (i.e.,
Benefit Type Claim Days), the effective date of each indemnity benefit (i.e.,
Benefit Period Start Date), and the date through which indemnity benefits were
paid at the time of reporting (i.e., Benefit Period Through Date), unless
otherwise indicated below. For purposes of the Electronic Claim Cost Report,
the Benefit Period Start Date shall be reported as the earliest date benefits
were paid for a Benefit Type Code, regardless of whether multiple disability
periods were paid for the Benefit Type Code.
(1) Benefit Type (BT) Codes:
(a) BT Code 010: Fatal/Death.
(b) BT Code 020: Permanent Total
(PT).
(c) BT Code 021: Permanent
Total Supplemental (PT Supp).
(d)
BT Code 030: Permanent Partial Scheduled/Impairment Income Benefits (IB) (Dates
of Injury on or after 1/1/94).
The claim administrator shall not report BT Code 030 (IB) or
BT Code 530 (Lump Sum Payment/Settlement of IB) if one or more of the following
BT Codes have been paid: BT Code 020 (PT), 021 (PT Supp), 520 (Lump Sum
Payment/Settlement of PT), or 521 (Lump Sum Payment/Settlement of PT
Supp).
(e) BT Code 030:
Permanent Partial Scheduled/Wage Loss Benefits (Dates of Injury prior to
1/1/94).
1. Benefit Type Claim Weeks, Benefit
Type Claim Days, Benefit Period Start Date and Benefit Period through Date are
not required to be reported.
(f) BT Code 040: Permanent Partial
Unscheduled/Supplemental Income Benefits (SB) (Dates of Injury 1/194 through
9/30/2003).
1. BT Code 040 (SB) or 540 (Lump
Sum Payment/Settlement of SB) shall not be sent as the earliest/only indemnity
benefit paid.
(g) BT Code
050: Temporary Total (TT).
(h) BT
Code 051: Temporary Total Catastrophic (TT @ 80%).
(i) BT Code 070: Temporary Partial (TP).
For Dates of Injury prior to 1/1/94, Benefit Type Claim
Weeks, Benefit Type Claim Days, Benefit Period Start Date and Benefit Period
through Date are not required to be reported.
(j) BT Code 090: Permanent Partial
Disfigurement/Permanent Impairment Benefits (PI) (Dates of Injury 8/1/79
through 12/31/1993).
1. The claim
administrator shall not report BT Code 090 (PI) or BT Code 590 (Lump Sum
Payment/Settlement of PI) if one or more of the following BT Codes have been
paid: BT Code 020 (PT), 021 (PT Supp), 520 (Lump Sum Payment/Settlement of PT),
or 521 (Lump Sum Payment/Settlement of PT Supp).
2. Benefit Type Claim Weeks, Benefit Type
Claim Days, Benefit Period Start Date and Benefit Period through Date are not
required to be reported.
(k) BT Code 240: Employer Paid
Unspecified/Salary in Lieu of Compensation.
1.
The claim administrator may alternatively report BT Code 242: Employer Paid
Vocational Rehab Maintenance/specifically for Salary in Lieu of Comp for TT -
Training and Education; BT Code 250: Employer Paid Temporary Total/specifically
for Salary in Lieu of Comp for TT; BT Code 251: Employer Paid Temporary Total
Catastrophic/specifically for Salary in Lieu of Comp for TT @ 80%; and/or BT
Code 270: Employer Paid Temporary Partial/specifically for Salary in lieu of
Comp for TP Payable; however, if the claim administrator's knowledge of the
injury is on or after its production implementation date for reporting the
Electronic Claim Cost Report, BT Codes 242, 250, 251, and 270 shall not be
reported with BT Code 240.
2.
Benefit Type Amount Paid is not required to be reported for BT Codes 240, 242,
250, 251, and 270.
(l) BT
Code 410: Vocational Rehab Maintenance/TT Training and Education.
(m) BT Code 500: Unspecified Lump Sum
Payment/Settlement of indemnity benefits.
Benefit Type Claim Weeks, Benefit Type Claim Days, Benefit
Period Start Date and Benefit Period through Date are not required to be
reported.
(n) BT Code 501:
Medical Lump Sum Payment/Settlement. The claim administrator is not required to
report BT Code 501: Medical Lump Sum Payment/Settlement, unless it is
accompanied or preceded by BT Code 500 Unspecified Lump Sum Payment/Settlement.
1. If BT Code 501 is the only payment
reported, the Electronic Claim Cost Report will be rejected.
2. Benefit Type Claim Weeks, Benefit Type
Claim Days, Benefit Period Start Date and Benefit Period through Date are not
required to be reported.
(o) BT Codes 5xx: Lump Sum Payment/Settlement
of a specific BT Code in paragraphs (1)(a) through (l) of this subsection.
Benefit Type Claim Weeks, Benefit Type Claim Days, Benefit
Period Start Date and Benefit Period through Date are not required to be
reported.
(2)
Other Benefit Type (OBT) Codes:
(a) OBT Code
300: Funeral Expenses.
(b) OBT Code
310: Total Penalties.
The claim administrator shall not report OBT Code 310 for
cases where the Date Claim Administrator Had Knowledge of the Injury is prior
to the claim administrator's production implementation date for Electronic
Claim Cost Reports (MTC's SA and FN).
(c) OBT Code 311 - Total Employee Penalties.
The claim administrator shall file OBT Code 311(versus OBT
Code 310) for cases where the Date Claim Administrator Had Knowledge of the
Injury is on or after the claim administrator's production implementation date
for Electronic Claim Cost Reports (MTC's SA and FN).
(d) OBT Code 320 - Total Interest.
The claim administrator shall not report OBT Code 310 for
cases where the Date Claim Administrator Had Knowledge of the Injury is prior
to the claim administrator's production implementation date for Electronic
Claim Cost Reports (MTC's SA and FN).
(e) OBT Code 321 - Total Employee Interest.
The claim administrator shall file OBT Code 321(versus OBT
Code 320) for cases where the Date Claim Administrator Had Knowledge of the
Injury is on or after the Claim Administrator's production implementation date
for Electronic Claim Cost Reports (MTC's SA and FN).
(f) OBT Code 370: Total Other Medical.
OBT Code 370 includes medical expenses (e.g., expenses to
build a ramp for a wheelchair-bound employee) not otherwise required to be
reported to the Division pursuant to rule
69L-7.602, F.A.C., (i.e.,
physician, dental, hospital, pharmacy or durable medical
expenses).
(g) OBT Code 380:
Total Vocational Rehabilitation Evaluation.
(h) OBT Code 390: Total Vocational
Rehabilitation Education.
(i) OBT
Code 400: Total Other Vocational Rehabilitation.
(j) OBT Code 430: Total Unallocated Prior
Indemnity Benefits.
(k) OBT Code
475: Total Medical Travel Expenses.
(3) The claim administrator shall send
Electronic Periodic Claim Cost Reports to the Division for the following cases
and by the filing time periods in subsection (3) of this section:
(a) "Lost Time/Indemnity Case";
(b) "Medical Only to Lost Time
Case;
(c) "Denied Case" for which
any indemnity benefit was paid prior to or after the
denial.
(4)
(a) Electronic Sub-Annual Claim Cost Report:
The claim administrator shall report the Electronic Sub-Annual Claim Cost
Report by sending SROI MTC SA (Sub-Annual) every 6 months after the date of
injury until the claim is closed. The first Electronic Sub-Annual Claim Cost
Report 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) within 30 days after six (6) months from the date of
injury. All subsequent Electronic Sub-Annual Claim Cost Reports shall be sent
to the Division every six (6) months thereafter. A subsequent Electronic
Sub-Annual Claim Cost Report 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) within 30 days of the due
date as determined by the following: A subsequent MTC SA due date will be
determined by adding six month intervals to the month of injury (e.g. Date of
Injury (DOI) = 3/15/06, MTC SA due 9/15/06, next MTC SA due 3/15/07). If the
resulting MTC SA due date is not a valid calendar date, the due date for that
MTC SA will default to last day of the calculated month (e.g. DOI = 8/30/06,
MTC SA due 2/28/07, next MTC SA due 8/30/07).
1. The first Electronic Sub-Annual Claim Cost
Report shall not be sent to the Division earlier than six months after the date
of injury. However, if the claim administrator closed the case prior to 6
months after the date of injury, the first Electronic Claim Cost Report may be
sent prior to six (6) months after the date of injury if it is sent as an
Electronic Final Claim Cost Report (MTC FN). If the claim did not become a
"Lost Time/Indemnity Case" until more than six (6) months after the date of
injury, the first Electronic Sub-Annual Claim Cost Report shall be filed when
the next "6 month" SROI MTC SA becomes due (e.g., disability began 9 months
after the DOI, 1st MTC SA due 12 months after DOI; disability began 13 months
after DOI, 1st MTC SA due 18 months after DOI).
2. Subsequent Electronic Sub-Annual Claim
Cost Reports sent more than 7 days prior to the required six (6) month filing
interval will be processed as an amendment to the previous Electronic
Sub-Annual Claim Cost Report and will not fulfill the filing requirement for
the next required Electronic Sub-Annual Claim Cost Report.
(b) Electronic Final Claim Cost Report: The
claim administrator shall report the Electronic Final Claim Cost Report by
sending SROI MTC FN (Final) for all cases closed since the last required filing
of a periodic report. The Electronic Final Claim Cost Report 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 30 days after the due date of the sub-annual.
1. The Electronic Final Claim Cost Report may
be sent prior to the due date of the sub-annual if the claim administrator
closes the case and will not be paying any further medical or indemnity
benefits.
2. If the claim
administrator issues payment or changes the amount paid for any Benefit Type
Code or Other Benefit Code identified in subsections
69L-56.3013(1) and
(2), F.A.C., since the filing of the previous
Final Claim Cost Report, the claim administrator shall send an Electronic Final
Claim Cost Report on or before 30 days after the due date of the sub-annual to
summarize benefits paid since the last Final Claim Cost Report filed with the
Division.
3. If the claim
administrator is re-opening the claim to pay on-going indemnity benefits, the
Electronic Periodic Claim Cost Report should be sent as an Electronic
Sub-Annual (SA) Claim Cost Report on or before 30 days after the due date of
the Sub-Annual.
4. The claim
administrator shall file another Electronic Final (FN) Claim Cost Report if it
has paid additional amounts for one or more of the following Other Benefit Type
Codes: OBT Code 370 (Total Other Medical), OBT Code 380 (Total Vocational
Rehabilitation Evaluation), OBT Code 390 (Total Vocational Rehabilitation
Education), OBT Code 400 (Total Other Vocational Rehabilitation), or OBT Code
475 (Total Medical Travel Expenses).
(5) Any insurer failing to timely send an
Electronic Periodic Claim Cost Report 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.
(6) In the event claims are
acquired from another claim administrator, the insurer shall ensure that its
former claim administrator provides the acquiring claim administrator with the
total amounts paid for indemnity benefits paid prior to the acquisition of the
claim by the new claim administrator. Notwithstanding the provision of specific
claim costs amounts paid by the former claim administrator(s) for each
indemnity benefit type, the acquiring claim administrator shall report on the
next required Electronic Periodic Claim Cost Report, cumulative totals for all
indemnity benefits paid by the former claim administrator(s) on a transferred
case as follows: Cumulative totals for indemnity costs paid by the former claim
administrator(s) shall be reported under Other Benefit Type Code 430 (Total
Unallocated Prior Indemnity Benefits). The acquiring claim administrator shall
report any specific costs paid by the acquiring claim administrator for each
applicable Benefit Type Code (indemnity benefits) and Other Benefit Type Code,
in addition to the unallocated indemnity amount paid by the former claim
administrator(s).
