Fla. Admin. Code Ann. R. 69L-56.4011 - First Report of Injury or Illness: Claim Administrator's Responsibility to Record and Report Accidents

(1) A claim administrator shall record all industrial injuries and diseases as follows:

(a) Upon receipt of a Form DFS-F2-DWC-1, as adopted in Rule 69L-3.025, F.A.C., the claim administrator shall legibly date stamp the form in the "Received by Claims-handling Entity" box. Upon notification of the injury by any other means, the claim administrator shall record the earliest date of notification in the file and on the Form DFS-F2-DWC-1.

(b) If the employer notifies the claim administrator of the injury by telephone or electronic data interchange, the claim administrator shall produce and mail to the employee and employer a paper copy of Form DFS-F2-DWC-1, as adopted in Rule 69L-3.025, F.A.C., within 3 business days of the claim administrator's knowledge of the injury. However, if the claim administrator is electronically sending the first report of injury information required in Rule 69L-56.4011, F.A.C., Form IA-1, Workers Compensation - First Report of Injury or Illness, ^©IAIABC 2002, as adopted in Rule 69L-3.025, F.A.C., may be sent to the employee and employer.

(c) The claim administrator shall make reasonable efforts to confirm that the following information on the Form DFS-F2-DWC-1 is correct:

1. Employee's name.

2. Social security number or other identifying number pursuant to paragraph 69L-3.003(3)(b), F.A.C.

3. Employee's mailing address.

4. Employee's telephone number (if provided by the employee or employer).

5. Date (mm-dd-yy or mm-dd-ccyy) and time of accident.

6. Occupation of the employee.

7. Location of the accident.

8. Description of the accident, including the cause and nature of the injury, and part(s) of the body affected.

(d) The claim administrator shall complete the "Claims-handling Entity Information" section of Form DFS-F2-DWC-1 as follows:

1. "Insurer Code #".

2. "Service Co/TPA Code #", if applicable.

3. The "Insurer Name" and the "Claims-handling Entity Name, Address, & Telephone" as applicable. When a "Service Co/TPA" is adjusting claims for an insurer, the name, address and telephone number of the "Service Co/TPA" in addition to the name of the insurer shall be given. The telephone number provided shall enable a caller to readily contact the office handling the claim.

4. "Claims-handling Entity File #".

5. Indicate the status of the case by marking the appropriate box: "Denied Case", "Indemnity Only Denied Case," "Medical Only Which Became Lost Time Case," or "Lost Time Case." In addition, the following information is required:

a. "Denied Case": When the liability for the claim is being totally denied, Form DFS-F2-DWC-12, as adopted in Rule 69L-3.025, F.A.C., shall be filed with the Division at the same time as the Form DFS-F2-DWC-1 pursuant to rule 69L-56.4012, F.A.C.

b. "Indemnity Only Denied Case": When only indemnity benefits are being denied, a Form DFS-F2-DWC-12 shall be filed with the Division at the same time as the Form DFS-F2-DWC-1, pursuant to Rule 69L-56.4012, F.A.C.

c. "Medical Only Which Became Lost Time Case":

(I) Delayed disability cases: The fields for "First Date of Disability," "Date First Payment Mailed," "AWW," "Comp Rate," "Employee's 8th Day of Disability," the "Entity's Knowledge of the 8th Day of Disability" and the type of initial benefit paid shall be provided, except as indicated in sub-subparagraph (1)(d)5.f. of this rule.

(II) IB Only Cases: The "Date First Payment Mailed," "AWW," "Comp Rate," the type of initial benefit paid identified as "I.B."

(III) Settlement Only Cases: The "Date First Payment Mailed", the type of initial benefit paid identified, as "Settlement Only" shall be provided.

d. "Lost Time Cases": The "First Date of Disability," "Date First Payment Mailed," "AWW," "Comp Rate" and the type of initial benefit paid shall be provided except as indicated in sub-subparagraph (1)(d)5.f. of this rule.

e. "Full Salary End Date." If the employer paid full salary in lieu of compensation and the claim administrator has knowledge of the day the employer discontinued paying full salary, the "Full Salary In Lieu of Comp" box is to be checked "Yes" and the "Full Salary End Date" field on the DFS-F2-DWC-1 must be completed when the DFS-F2-DWC-1 is filed.

f. Exceptions to sub-subparagraphs (1)(d)5.c. and d. of this rule. The following data fields are not required for the filing of Form DFS-F2-DWC-1:

(I) If the employer is continuing full salary in lieu of compensation, the "Date First Payment Mailed," "AWW," and "Comp Rate" are not required.

(II) If a compensable volunteer has a lost time case, "Date First Payment Mailed," "AWW," and "Comp Rate" are not required unless the compensable volunteer meets statutory requirements to be paid for concurrent employment.

(III) If the employee's death is compensable and the employee has no known dependents, the "Date First Payment Mailed" is not required.

(e) The claim administrator shall report to the Division the "Employee's Class Code" based on the National Council on Compensation Insurance (NCCI) classification system (Scopes Manual), and the "Employers' NAICS Code" based on the North American Industrial Classification System (NAICS). The information shall be reported on Form DFS-F2-DWC-1 if the information is available at the time of filing with the Division. If either code is not available at time of filing, this information shall be filed on Form DFS-F2-DWC-4 pursuant to subsection 69L-56.404(14), F.A.C.

(f) If the initial payment of compensation was not timely paid in accordance with Section 440.20, F.S., the claim administrator shall also report the following information, where applicable:

1. "Penalty Amount Paid in 1st Payment"; and,

2. The "Interest Amount Paid in 1st Payment."

(2) The claim administrator shall report industrial injuries or illnesses to the Division as follows:

(a) When disability is immediate and continuous for 8 or more days, the claim administrator shall send a completed Form DFS-F2-DWC-1 within 14 days after the claim administrator's knowledge of the injury or illness for the following cases:

1. Initial lost time cases;

2. Death cases with or without dependents;

3. Lost time cases in which the employer continued full salary in lieu of compensation for 8 or more days;

4. Lost time cases for a compensable volunteer.

(b) When disability is not immediate and continuous but resulted in 8 or more days of disability, the claim administrator shall send a completed Form DFS-F2-DWC-1 within 6 days after the claim administrator's knowledge of the eighth day of disability for the following cases:

1. Medical only to lost time cases, delayed disability;

2. Cases involving multiple periods of disability;

3. Cases in which the employer continued full salary in lieu of compensation;

4. Lost time cases for a compensable volunteer.

(c) If the initial payment of indemnity benefits is for temporary partial, the claim administrator shall send to the Division a completed Form DFS-F2-DWC-1 within 14 days after the date payment mailed.

(d) If the initial payment of indemnity benefits is for impairment benefits, the claim administrator shall send to the Division a completed Form DFS-F2-DWC-1 within 14 days after the date payment mailed.

(e) When the initial payment of indemnity results from an agreement or order for indemnity benefits, and a Form DFS-F2-DWC-1 was not previously filed, the claim administrator shall send to the Division a completed Form DFS-F2-DWC-1 within 14 days after the date payment mailed.

(f) For all cases denied in their entirety, the claim administrator shall send to the Division completed Forms DFS-F2-DWC-1 and DFS-F2-DWC-12 within 14 days of its knowledge of the injury or illness.

(g) For cases where the claim administrator denied only indemnity benefits and is paying medical benefits for the employee, the claim administrator shall send to the Division completed Forms DFS-F2-DWC-1 and DFS-F2-DWC-12 within 14 days after denial of the indemnity benefits.

(h) Medical Only Cases shall not be sent to the Division unless the claim administrator has received a written request from the Division. The claim administrator shall send Form DFS-F2-DWC-1 within 14 days of receipt of the request. The notation "MO Filed Pursuant to Division Request" shall be provided in the "Remarks" field.

(3) This rule does not supersede Division filing requirements found in Rule 69L-56.301, F.A.C., and the filing requirements found herein only apply to circumstances under which a Petition for Variance or Waiver has been granted pursuant to Section 120.542, F.S.

Notes

Fla. Admin. Code Ann. R. 69L-56.4011

Rulemaking Authority 440.14(5), 440.185(2), (5), (9), 440.20(3), 440.207(2), 440.51(8), (9), 440.591 FS. Law Implemented 440.12, 440.185(2), (5), (9), 440.20(2)(a), (6), 440.41 FS.

New 4-11-90, Amended 1-30-91, 11-8-94, 12-5-96, Formerly 38F-3.0045, 4L-3.0045, Amended 1-10-05, 6-30-14, Formerly 69L-3.0045.

New 4-11-90, Amended 1-30-91, 11-8-94, 12-5-96, Formerly 38F-3.0045, 4L-3.0045, Amended 1-10-05, 6-30-14, Formerly 69L-3.0045.