Fla. Admin. Code Ann. R. 69L-56.3045 - Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by Insurer's Secondary Implementation Guide

(SROI MTC 02, CA, CB, AB, S1-S8, P7, RB, ER as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2009 Edition.)

(1) Electronic Notice of Action or Change (SROI MTC 02). On or before the compliance date established in the insurer's Secondary Implementation Schedule set forth in paragraph 69L-56.300(3)(b), F.A.C., the insurer shall file an Electronic Notice of Action or Change for the reporting of changes to the information in paragraphs (1)(a) and (b) of this section. The claim administrator shall file the SROI MTC 02 (Change) on or before 14 days after the claim administrator has knowledge of the new or changed information. However, MTC 02 shall not be sent if a data element changes as a result of an event that requires the reporting of another MTC pursuant to the definition of Maintenance Type Code (MTC) in the Data Dictionary located in Section 6 of the IAIABC Claims EDI Release 3 Implementation Guide.

(a) The claim administrator shall file SROI MTC 02 (Change) and provide Form DFS-F2-DWC-4 unless otherwise noted in subparagraphs 1.-10. below, to the employee and employer, pursuant to Rules 69L-56.404 and 69L-3.025, F.A.C., if any of the following data elements are changed:

1. Date of Maximum Medical Improvement.

2. Permanent Impairment Percentage.

3. Initial Return to Work Date.

4. Current Return to Work Date.

5. Return to Work Type Code.

6. Physical Restrictions Indicator.

7. Permanent Impairment Minimum Payment Indicator - No DFS-F2-DWC-4 required.

8. Return to Work with Same Employer Indicator - No DFS-F2-DWC-4 required.

9. Suspension Effective Date.

10. Suspension Narrative - No DFS-F2-DWC-4 required.

(b) The claim administrator shall file SROI MTC 02 and provide Form DFS-F2-DWC-4 unless otherwise noted in subparagraphs 1.-15. below, to the employee and employer, pursuant to Rules 69L-56.404 and 69L-3.025, F.A.C., if any of the following data elements are changed and there is no resulting change to the Net Weekly Amount because the benefit type being paid will continue to be paid at the same statutory maximum weekly rate, or because the claim administrator is correcting a code, date or amount previously reported in error and the Net Weekly Amount is unchanged:

1. Average Wage.

2. Wage Effective Date.

3. Calculated Weekly Compensation Amount.

4. Gross Weekly Amount - No DFS-F2-DWC-4 required.

5. Gross Weekly Amount Effective Date - No DFS-F2-DWC-4 required.

6. Net Weekly Amount Effective Date - No DFS-F2-DWC-4 required.

7. Benefit Adjustment Code.

8. Benefit Adjustment Start Date.

9. Benefit Adjustment End Date.

10. Benefit Credit Code.

11. Benefit Credit Start Date.

12. Benefit Credit End Date.

13. Benefit Redistribution Code.

14. Benefit Redistribution Amount.

15. Benefit Redistribution Start Date.

16. Benefit Redistribution End Date.

When the claim administrator is commencing or suspending redirection of a portion of the Net Weekly Amount to another party on the behalf of the employee or the employee's beneficiary due to a court ordered lien for child support, the claim administrator shall report Benefit Redistribution Code "H" that is being applied to a specific indemnity benefit type, and file SROI MTC 02 on or before 14 days after the date the claim administrator has knowledge that a portion of the net weekly amount should be redistributed to another party due to an income deduction order pursuant to Section 61.1301, F.S., or when the redistribution has ended.

(2) Electronic Change in Amount (MTC CA): If the Net Weekly Amount changes from the amount previously reported due to a revised Average Wage (e.g., wage statement, discontinuation of fringe benefits), or due to the application of a Benefit Adjustment Code or Benefit Credit Code specified in paragraph (2)(a) of this section, the claim administrator shall file a SROI MTC CA (Change in Benefit Amount) on or before 14 days after the date the claim administrator has knowledge that the Net Weekly Amount should be amended.

(a) When the claim administrator applies an adjustment or credit which reduces the Net Weekly Amount for a specific indemnity benefit type, the claim administrator shall report the Benefit Adjustment Code or Benefit Credit Code being applied to the specific indemnity benefit type, and file SROI MTC CA (Change in Amount) to report the change as follows:

1. Benefit Adjustment Codes:

a. "A" = Apportionment/Contribution. The weekly payment amount is reduced for shared or partial liability with another party.

b. "B" = Subrogation (Third Party Offset). The weekly payment amount is reduced for recovery from third party tort-feasor pursuant to section 440.39(2), F.S.

c. "N" = Non-cooperation: Rehabilitation, Training, Education, and Medical. The weekly payment amount is reduced because the employee failed to accept training and education pursuant to Section 440.491(6)(b), F.S., for dates of accident prior to October 1, 2003, or the employee failed to timely cancel an independent medical examination pursuant to Section 440.13(5)(d), F.S.

d. "R" = Social Security Retirement. The weekly payment amount is reduced for retirement benefits paid under the Federal Old Age, Survivors, and Disability Insurance Act, pursuant to Section 440.15(9), F.S.

e. "S" = Social Security Disability. The weekly payment amount is reduced for disability benefits paid under the Federal Old Age, Survivors, and Disability Insurance Act, pursuant to Section 440.15(9), F.S.

f. "U" = Unemployment Compensation. The weekly payment amount is reduced for payment of unemployment compensation insurance benefits, pursuant to Section 440.15(10), F.S.

g. "V" = Safety Violation. The weekly payment amount is reduced for safety violation(s) pursuant to Section 440.09(5), F.S.

h. "X" = Death Benefit Reduction (Dependent Change). The weekly payment amount is reduced because of a change in number or kind of dependents entitled to death benefits pursuant to Section 440.16, F.S.

2. Benefit Credit Codes:

a. "C" = Overpayment. The weekly payment amount is reduced for recoupment of benefits paid but not due.

b. "P" = Advance. The weekly payment amount is reduced for reimbursement of benefit payments advanced pursuant to section 440.20(13), F.S.

(b) In addition to filing MTC CA with the Division, the claim administrator shall provide Form DFS-F2-DWC-4 to the employee and employer as required by Rules 69L-56.404 and 69L-3.025, F.A.C.

(c) If the Net Weekly Amount is adjusted due to the application of a Social Security Offset, the claim administrator shall also send to the Division a completed Form DFS-F2-DWC-14, Request for Social Security Disability Benefit Information, adopted in Rules 69L-3.021 and 69L-3.025, F.A.C., at the same time the claim administrator sends the SROI MTC CA to report the change in the Net Weekly Amount.

(d) If the Net Weekly Amount changes due to a change in the type of indemnity benefits that are being paid, the claim administrator shall file MTC CB (Change in Benefits) required by subsection 69L-56.3045(3), F.A.C., to report a change in the Benefit Type Code (BTC) that results in a change in the Net Weekly Amount payable (e.g., when indemnity benefits change from BTC 050 (Temporary Total) to BTC 070 (Temporary Partial) or BTC 030 (Impairment Income) - The claim administrator shall not file MTC CA (Change in Amount) for this occurrence.

(e) MTC CA is not required to report subsequent changes in the Net Weekly Amount payable for BTC 070 (Temporary Partial) for interim or ongoing fluctuations in the weekly rate due to variations in the employee's weekly earnings, or to report subsequent changes to the Net Weekly Amount payable for BTC 030 (Impairment Income Benefits) due to changes in the employee's weekly work status.

(f) MTC CA is also not required to be filed if the Net Weekly Amount changes due to subsequent applications of varying weekly adjustment or credit amounts against BTC 070 (Temporary Partial) or BTC 030 (Impairment Income) benefits. MTC CA, however, shall be filed to report a change in the Net Weekly Amount due to the ending of an adjustment or credit against BTC 070 (Temporary Partial) or BTC 030 (Impairment Income) benefits.

(3) Electronic Change in Benefit Type (MTC CB): When an indemnity benefit type being paid changes and payments are being continued under a different indemnity benefit type without a break in continuity of payments, the claim administrator shall file a SROI MTC CB (Change in Benefit Type) on or before 14 days after the date the claim administrator has knowledge that the indemnity benefit type being paid should be changed.

(4)

(a) Adding Concurrent Benefit (MTC AB): When Permanent Total Benefits (Benefit Type 020) are being paid, and Permanent Total Supplemental Benefits (Benefit Type Code 021) are initiated subsequent to the prior commencement of Permanent Total Benefits (Benefit Type Code 020), the claim administrator shall file SROI MTC AB (Add Concurrent Benefit Type) on or before 14 days after the date the claim administrator has knowledge that Permanent Total Supplemental Benefits (Benefit Type Code 021) should be commenced.

(b) In addition to filing MTC AB with the Division, the claim administrator shall provide Form DFS-F2-DWC-4 to the employee and employer as required by Rules 69L-56.404 and 69L-3.025, F.A.C.

(5)

(a) Electronic Suspension of all indemnity benefits (MTC S1-S8): When all indemnity benefits are suspended because the employee returned to work, or was medically released to return to work and the claim administrator does not anticipate paying further indemnity benefits of any kind, the claim administrator shall file with the Division SROI MTC S1 (Suspension, RTW, or Medically Determined/Qualified RTW) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits.

(b) When all indemnity benefits are suspended because the employee failed to report for an independent medical examination pursuant to Section 440.13(5)(d), F.S., or failed to report for an evaluation by an expert medical advisor appointed by a Judge of Compensation Claims pursuant to Section 440.13(9)(c), F.S., the claim administrator shall file with the Division SROI MTC S2 (Suspension, Medical Non-compliance) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits.

(c) When all indemnity benefits are suspended because the employee failed to comply with one or more of the following statutory sections and rules, the claim administrator shall file with the Division SROI MTC S3 (Suspension, Administrative Non-compliance) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits:

1. Section 440.15(1)(e)3., F.S. (1994), which is incorporated herein by reference - Employee in Permanent Total status failed to attend vocational evaluation or testing.

2. Section 440.15(1)(f)2.b., F.S. (1994), which is incorporated herein by reference - Employee in Permanent Total status failed to report or apply for Social Security benefits.

3. Section 440.15(2)(d), F.S. (1994), which is incorporated herein by reference - Employee in Temporary Total status failed or refused to complete and return the Form DFS-F2-DWC-19 adopted in Rules 69L-3.021 and 69L-3.025, F.A.C.

4. Section 440.15(7), F.S. (1994), which is incorporated herein by reference - Employee in Temporary Partial status failed or refused to complete and return the Form DFS-F2-DWC-19 adopted in Rules 69L-3.021 and 69L-3.025, F.A.C.

5. Section 440.15(6), F.S. (2003), which is incorporated herein by reference - Employee refused suitable employment.

6. Section 440.15(9), F.S. (2003), which is incorporated herein by reference - Employee failed or refused to sign and return the release for Social Security benefits earnings on Form DFS-F2-DWC-14, or unemployment compensation earnings on Form DFS-F2-DWC-30 adopted in Rule 69L-3.025, F.A.C.

7. Section 440.491(6)(b), F.S. (2003), which is incorporated herein by reference - Employee failed or refused to accept vocational training or education.

8. Section 440.15(4)(d), F.S. (2003), which is incorporated herein by reference - Employee in Temporary Partial status failed to notify the claims-handling entity of the establishment of earnings capacity within 5 business days of returning to work.

9. Section 440.15(4)(e), F.S. (2003), which is incorporated herein by reference - Employee in Temporary Partial status terminated from post-injury employment due to the employee's misconduct.

10. Section 440.105(7), F.S. (2003), which is incorporated herein by reference - Employee refused to sign and return the fraud statement.

(d) When all indemnity benefits are suspended because the employee died and there are no known or confirmed dependents to whom death benefits must be paid, or if the death was not compensable, the claim administrator shall file with the Division SROI MTC S4 (Suspension, Claimant Death) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits.

(e) When all indemnity benefits are suspended because the employee became an inmate of a public institution and there are no known or confirmed dependents to whom indemnity benefits must be paid, the claim administrator shall file with the Division SROI MTC S5 (Suspension, Incarceration) on or before 14 days from the date the claim administrator decided to suspend all indemnity benefits.

(f) When all indemnity benefits are suspended because the claim administrator's good faith repeated attempts to locate and send indemnity benefits to the employee have been unsuccessful; or the employee has no known address, representative or guardian to whom the claim administrator can send indemnity benefits; or indemnity benefits have been returned to the claim administrator indicating that the employee has moved and the current or forwarding address is unknown, or the employee no longer resides at the last known address, the claim administrator shall file with the Division SROI MTC S6 (Suspension, Claimant's Whereabouts Unknown) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits.

(g) When all indemnity benefits are suspended because the employee is no longer eligible for or entitled to any indemnity benefits because the limits of or entitlement to indemnity benefits have been exhausted, the claim administrator shall file with the Division SROI MTC S7 (Suspension, Benefits Exhausted) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits.

(h) When all indemnity benefits are suspended because the employee elects to receive workers' compensation benefits under another state's law, or the claim administrator determines the claim is compensable under another compensation act, such as the Federal Employers' Liability Act, the Federal Employees' Compensation Act, the U.S. Longshoremen's and Harbor Workers' Compensation Act, or the Jones Act, the claim administrator shall file with the Division SROI MTC S8 (Suspension, Jurisdiction Change) on or before 14 days after the date the claim administrator decided to suspend all indemnity benefits. Until the claim administrator implements the electronic reporting of suspension information as required in Rules 69L-56.304 and 69L-56.3045, F.A.C., the claim administrator shall file Form DFS-F2-DWC-4, Notice of Action/Change adopted in Rules 69L-56.404 and 69L-3.025, F.A.C., and report Suspension Reason Code "S8" when there is a change in jurisdiction; however, once the claim administrator is in production status with filing electronic suspension notices, the claim administrator shall report a change in jurisdiction by filing SROI MTC S8 (Suspension, Jurisdiction Change).

(i) In addition to filing MTC SROI S1-S8 with the Division, the claim administrator shall provide Form DFS-F2-DWC-4 to the employee and employer as required by Rules 69L-56.404 and 69L-3.025, F.A.C.

(j) When Permanent Total Supplemental Benefits (Benefit Type 021) are suspended but Permanent Total Benefits (Benefit Type 020) will continue to be paid, the claim administrator shall file with the Division SROI MTC P7 (Partial Suspension, Benefits Exhausted) on or before 14 days after the date Permanent Total Supplemental Benefits were suspended. In addition to filing MTC P7 with the Division, the claim administrator shall provide Form DFS-F2-DWC-4 to the employee and employer as required by Rules 69L-56.404 and 69L-3.025, F.A.C.

(6) Electronic Reinstatement of Indemnity Benefits (MTC RB, ER):

(a) When payment of indemnity benefits are resumed by the claim administrator after having been previously suspended, the claim administrator shall file with the Division a SROI MTC RB (Reinstatement of Benefits) on or before 14 days after the date the claim administrator had knowledge of the need to reinstate indemnity benefits. In addition to filing SROI MTC RB with the Division, the claim administrator shall provide Form DFS-F2-DWC-4 to the employee and employer as required by Rules 69L-56.404 and 69L-3.025, F.A.C.

(b) When the employer reinstates payment of salary in lieu of compensation following a prior suspension of all indemnity benefits paid by the employer, the claim administrator shall file with the Division SROI MTC ER (Employer Reinstatement) on or before 14 days after the date the claim administrator received notification about the reinstatement of salary in lieu of compensation. Form DFS-F2-DWC-4 is not required to be sent to the employee or employer.

Notes

Fla. Admin. Code Ann. R. 69L-56.3045

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.