Fla. Admin. Code Ann. R. 69L-56.304 - Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer's Primary Implementation Schedule

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(FROI/SROI MTC 02, FROI MTC AQ, AU, SROI IP, PY, EP 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 (MTC 02). 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 an Electronic Notice of Action or Change for reporting changes to the information specified in paragraphs (1)(a) and (b) of this section. The claim administrator shall file the FROI or 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 in accordance with the definition of Maintenance Type Code (MTC) in the Data Dictionary located in Section 6 of the IAIABC Claims EDI Release 3 Implementation Guide. If there is a change in Insurer FEIN or Claims Administrator FEIN, Claim Administrator Postal Code, and Claim Administrator Claim Number due to the acquisition of a claim, the claim administrator shall file MTC AQ or AU with applicable SROI pursuant to subsection (2) of this section.

(a) The claim administrator shall file a FROI or SROI MTC 02 (Change) as noted below, and provide Form DFS-F2-DWC-4 to the employee and employer pursuant to Rules 69L-3.0091 and 69L-3.025, F.A.C., if any of the following data elements are changed or reported for the first time:

1. Insurer FEIN not due to change in claims administration (FROI or SROI MTC 02);

2. Claim Administrator FEIN not due to change in claims administration (FROI or SROI MTC 02);

3. Claim Administrator Postal Code not due to change in claims administration (FROI or SROI MTC 02);

4. Claim Administrator Claim Number not due to change in claims administration (FROI or SROI MTC 02);

5. Industry Code (FROI MTC 02 only);

6. Manual Classification Code (FROI MTC 02 only);

7. Employee SSN (FROI or SROI MTC 02);

8. Employee ID Assigned by Jurisdiction (FROI or SROI MTC 02);

9. Employee First/Last Name, Last Name Suffix, Middle Name/Initial (FROI or SROI MTC 02);

10. Date of Injury (FROI or SROI MTC 02);

11. Employee Date of Death (FROI or SROI MTC 02).

(b) The claim administrator shall file MTC 02 (Change) to report a change in any other data element designated with the requirement code of "Y", "Y¹", "Y^2", "Y^3", "Y⁴" or "FY" in the FROI or SROI MTC 02 column of the FL Claims EDI R3 Element Requirement Table contained in the FL Claims EDI Implementation Manual (e.g., Initial Date Disability Began, Benefit Payment Issue Date, etc.). The provision of Form DFS-F2-DWC-4 to the employee and employer is not required since these data elements are not contained on Form DFS-F2-DWC-4 adopted in Rules 69L-3.0091 and 69L-3.025, F.A.C.

(2) Electronic Notice of Action or Change in Claims Administration (MTC AQ, or MTC AU with applicable SROI MTC). If the responsibility for adjusting a "Lost Time/Indemnity Case", "Medical Only to Lost Time Case" or "Denied Case" has changed due to acquisition of the claim from another claim administrator or due to the employer transferring a large deductible claim to the claim administrator because the claim met the contracted deductible threshold, the new claim administrator shall send FROI MTC AQ (Acquired Claim), to report the change in claims administration, on or before 21 days after the effective date of the new claim administrator's acquisition of the claim. In place of filing FROI MTC AQ, the claim administrator may file FROI MTC AU (Acquired/Unallocated) with SROI MTC AP, EP, CD, VE, PY, or PD to report the change in claims administration. The claim administrator shall file FROI MTC AQ (Acquired Claim) or FROI MTC AU with applicable SROI MTC prior to sending any subsequent transactions (e.g., subsequent electronic suspension notices, electronic periodic claim cost reports, etc.).

(a) The acquiring claim administrator shall also provide to the employee and employer, Form DFS-F2-DWC-4 adopted in Rules 69L-3.0091 and 69L-3.025, F.A.C., or an explanatory letter, on or before 21 days from the date of acquisition, to advise the parties about the change in claims administration, except when sending Claims EDI filings identified in subparagraphs 69L-56.304(2)(c) 6.-7., below.

(b) A batch of FROI MTC AQ (Acquired Claim) filings or FROI AU with applicable SROI MTC filings to report a change in claims administration for multiple claims shall replace the former option of the claim administrator to otherwise file with the Division Form DFS-F2-DWC-49, Aggregate Claims Administration Change Report adopted in Rules 69L-3.0231 and 69L-3.025, F.A.C., in place of Form DFS-F2-DWC-4, Notice of Action/Change, for each affected claim.

(c) If the FROI MTC AQ (Acquired Claim) rejects because a First Report of Injury or Illness was not previously filed with the Division by the former claim administrator, the acquiring claim administrator shall file FROI MTC AU (Acquired/Unallocated) with the appropriate SROI MTC AP, EP, CD, VE, PY, PD, or 04 on or before 14 days after the FROI MTC AQ (Acquired Claim) was assigned an Application Acknowledgement Code "TR" (Transaction Rejected) as follows:

1. If the claim administrator is reporting its initial payment of indemnity benefits other than a lump sum payment/settlement for an acquired claim, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC "AU" (Acquired/Unallocated) with SROI MTC "AP" (Acquired/Payment).

2. If the claim administrator is reporting its initial payment of indemnity benefits for a lump sum payment or settlement for an acquired claim, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI MTC "PY" (Payment Report).

3. If the claim administrator is reporting the initial payment of indemnity benefits by the employer on an acquired claim (i.e., salary in lieu of compensation), the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI EP (Employer Paid).

4. If the claim administrator is reporting a Compensable Death, No Dependents/Payees on an acquired claim, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI MTC CD (Compensable Death, No Dependents/Payees).

5. If the claim administrator is reporting a compensable Volunteer on an acquired claim, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI MTC VE (Compensable Volunteer).

6. If the claim administrator is reporting a Partial (Indemnity Only) Denial on an acquired claim, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI MTC PD (Partial Denial).

a. The claim administrator shall file an Electronic Notice of Denial with the Division by reporting the applicable Partial Denial Reason Code and Denial Reason Narrative on the same SROI MTC PD (Partial Denial).

b. In addition to filing the Electronic Notice of Denial with the Division, the claim administrator shall provide a paper copy of Form DFS-F2-DWC-12, Notice of Denial, adopted in Rules 69L-3.012 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-3.012, F.A.C.

7. If the claim administrator is reporting a Full Denial on an acquired claim where indemnity payments were previously paid prior to the full denial, the Electronic Notice of a Change in Claims Administration shall be represented by sending FROI MTC AU (Acquired/Unallocated) with SROI MTC 04 (Denial).

a. The claim administrator shall file an Electronic Notice of Denial with the Division by reporting 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).

(d) If MTC AQ (Acquired Claim) rejects because a First Report of Injury or Illness was not previously filed with the Division by the former claim administrator, and the acquiring claim administrator is denying the entire claim where no indemnity payments have been made, the acquiring claim administrator shall file FROI MTC 04 (Denial) on or before 14 days after the FROI MTC AQ (Acquired Claim) was assigned an Application Acknowledgement Code "TR" (Transaction Rejected) as follows:

1. The claim administrator shall file an Electronic Notice of Denial with the Division by reporting the applicable Full Denial Reason Code(s) and Full Denial Effective Date on the FROI MTC 04 (Denial). The Denial Reason Narrative shall also be sent on the FROI MTC 04 (Denial) to supplement the Denial Reason Code(s).

2. In addition to filing the Electronic Notice of Denial with the Division, the claim administrator shall provide a paper copy of Form DFS-F2-DWC-12, Notice of Denial, adopted in Rules 69L-3.012 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-3.012, F.A.C.

(3) Electronic Notice to Report Initial Payment (MTC IP) Following Prior Employer Paid benefits, Compensable Death with no Known Dependants/Payees, or Compensable Volunteer Filing. If the claim administrator makes its initial payment following the prior initial payment of salary in lieu of compensation (SROI MTC EP), or after the prior filing of a SROI MTC CD (Compensable Death), or after the prior filing of a SROI MTC VE (Compensable Volunteer), the claim administrator shall file a SROI MTC IP (Initial Payment) on or before 14 days after the date the claim administrator's initial payment was mailed to the employee. The claim administrator shall provide Form DFS-F2-DWC-4 adopted in Rules 69L-3.0091 and 69L-3.025, F.A.C., or explanatory letter to the employee and employer regarding the commencement of indemnity benefits by the claim administrator.

(4) Electronic Notice of Lump Sum Payment/Settlement (MTC PY). If an order is signed for a lump sum payment or settlement of indemnity benefits subsequent to the initial payment of indemnity benefits, i.e., an award, advance, stipulated agreement, or final settlement of indemnity benefits, the claim administrator shall file SROI MTC PY (Payment Report), on or before 14 days after the date the award/order was signed. The claim administrator shall report the applicable Lump Sum Payment/Settlement Code as defined in Section 6, Data Dictionary, of the IAIABC Claims EDI R3 Implementation Guide as follows: "SF" (Settlement Full) if both indemnity and medical benefits are settled; "SP" (Settlement Partial) if only indemnity but not medical benefits are settled; "AS" (Agreement Stipulated) if the lump sum payment is for a non-adjudicated amount; "AW" (Award) if the lump sum payment is for an adjudicated amount; or "AD" (Advance) if the lump sum payment is for benefits in advance of when they were due. If all Impairment Income benefits due are paid in one lump sum amount, regardless of the amount, the claim administrator shall file SROI MTC PY with Benefit Type Code 030 or 530, and report Lump Sum Payment/Settlement Code "AD" (Advance). The claim administrator is not required to file an Electronic Notice of Suspension SROI MTC S7 (Suspension, Benefits Exhausted) to report the conclusion of the payment of Impairment Income benefits when Impairment Income benefits are paid in one lump sum.

(a) The claim administrator shall also report the "Payment Issue Date" on the SROI MTC PY. The Payment Issue Date shall represent the date payment for the lump sum payment/settlement leaves the control of the claim administrator for delivery to the employee or the employee's representative, and shall not be sent as the date the check is requested, created, or issued in the claim administrator's system unless the check leaves the control of the claim administrator the same day it is requested, created, or issued for delivery to the employee or the employee's representative.

(b) The claim administrator shall provide Form DFS-F2-DWC-4, Notice of Action/Change, adopted in Rules 69L-3.0091 and 69L-3.025, F.A.C., to the employee and employer.

(5) Electronic Notice to Report Employer Payment of Indemnity Benefits that is not the Initial Payment (MTC EP). If the employer pays an indemnity benefit(s) for the first time following payment of and suspension of all indemnity benefits by the claim administrator (e.g., when the employer elects to pay Impairment Income Benefits), the claim administrator shall file SROI MTC EP (Employer Paid) on or before 14 days after the date the claim administrator had knowledge of the payment of indemnity benefits by the employer. The provision of Form DFS-F2-DWC-4 to the employee and employer is not required.

(6) The filing of a FROI or SROI MTC 02 to report a change in Insurer FEIN, Claim Administrator FEIN, or Claim Administrator Postal Code and Claim Administrator Claim Number due to the establishment of a new or elimination of a claims office location or subsidiary entity within the insurer's organization does not negate the obligation of the trading partner (insurer or claim administrator) to file a revised "EDI Trading Partner Profile, DFS-F5-DWC-EDI-1 (1/01/2008), and if applicable, a revised "EDI Trading Partner Insurer/Claim Administrator ID List", DFS-F5-DWC-EDI-2 (10/01/2006), and if applicable, a revised "EDI Trading Partner Claim Administrator Address List", DFS-F5-DWC-EDI-2A (10/01/2006), pursuant to subsection 69L-56.300(2), F.A.C.

Notes

Fla. Admin. Code Ann. R. 69L-56.304

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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