FL Claims EDI Release 3 Training

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Florida Division of Workers Compensation
Claims EDI Basic Overview
2013
WELCOME
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Presenter Tonya Granger Administrator, Claims
POC EDI Team Bureau of Data Quality and
Collection FL Division of Workers Compensation
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• This training includes
• Overview of EDI terminology and
  Administrative Rule 69L-56, F.A.C.
• How to investigate errors and utilize EDI
  resources (e.g., Edit Matrix, Element Req.
  Table.) to understand errors and make necessary
  corrections.
• Review of various EDI scenarios.
  
  

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Rule Chapter 69L-56 of the
Florida Administrative Code is the EDI
Rule for Proof of Coverage and
Claims (non-medical)
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EDI Rule 69L-56 F.A.C. was effective on
January 7, 2007. It requires all
insurers to implement the IAIABC Claims EDI
Release 3 electronic format.
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So Heres A Little Background On EDI
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On a National level, in 1990 the IAIABC
spearheaded a program to utilize the concept of
EDI for Workers Compensation data.
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What is the IAIABC?

• The International Association of Industrial
  Accident Boards and Commissions.
• A 99 year old organization of jurisdictional
  workers compensation administrators and others
  interested in WC.

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What is EDI?

• Electronic Data Interchange is the electronic
  exchange of data between business trading
  partners (i.e., claim administrators to state
  agencies), in a standardized format.
• This does not include
  reporting by
• Injured Workers!

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Developing an Electronic Standard
Bringing Together the Important Participants
Jurisdictions
Carriers
Vendors
TPAs
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Developing a National Standard through the IAIABC
EDI Development Committees was a process that
required give and take from all participants.
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The end result is a national standard format for
the reporting of workers compensation data
electronically.
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FL DWC chose to implement the national standard
for Proof of Coverage and Claims reporting to
provide claim administrators with a consistent
standard for electronic reporting across multiple
states.
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Where can you find the IAIABC R3 Implementation
Guide Codes?
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www.iaiabc.org
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The IAIABC Release 3 Claims EDI Implementation
Guide contains essential information for
implementing EDI, including the transaction
record layouts, data dictionary, business and
technical rules, national scenarios, etc.
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The Release 3 Claims Implementation Guide can be
purchased for 195 from the IAIABCs website
www.iaiabc.org, or it is free if your company is
an IAIABC EDI Member. The latest R3
Guide is dated
January 1, 2013.
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The national standard format contains different
terminology, edits and various rules, such as
sequencing rules, that must be followed and may
be different from what you are accustomed to in
the paper reporting environment.
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Each Trading Partner should purchase the IAIABC
EDI Claims Release 3 Implementation Guide each
year. DWC can not furnish copies of any portions
of this Guide. Become familiar with the data
elements, definitions and other information in
the Guide.
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It is recommended that at least one person within
every company have access to the Claims EDI R3
Implementation Guide. The requirements of this
guide are incorporated by reference in the FL EDI
Rule 69L-56 F.A.C.
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STANDARD USAGE FOR ALL PRODUCTS
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Glossary
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Glossary
The purpose of the glossary is to acquaint the
reader with easy-to-understand definitions of
workers' compensation terms.
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Glossary
The glossary defines terms that are common to
FROI/SROI, MED, and POC EDI reporting. Not all
of the terms are directly related to one of the
IAIABC EDI reporting products, but they are
commonly used in the business and data reporting
environment.
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Glossary
Alphabetical by term
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Glossary
Terms that are specific to approved data
elements will be found in the Data Dictionary
sections of the individual Implementation Guides.
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Acronyms
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ACRONYMS

• EDI Committee participants frequently use
  acronyms in their discussions, and newcomers (and
  veterans, too!) can easily lose their place in
  what is going on if they dont understand what
  the acronyms stand for. 

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ACRONYMExamples
FTP File Transfer Protocol
FEIN Federal Employer Identification Number
FROI First Report of Injury
GUI Graphical User Interface
HTTP Hyper Text Transfer Protocol
SROI Subsequent Report of Injury
URL Uniform Resource Locator
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RELEASE 3
RELEASE 3
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Release 3 Combined
Business Technical Data Dictionary
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The IAIABC Release 3 Claims EDI Implementation
Guide contains the data dictionary, which defines
each element that is required. It is recommended
that this section be saved to your desktop for
ready reference.
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Release 3 Data Dictionary
Section 6 in the Implementation Guide
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Data Element Dictionary

• Identifies the Data Number (DN)

• Gives the Definition of the Data Element

• Gives the Last Revision Date of the Data
  Element

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Data Element Dictionary

• Gives the Format (i.e. 2 A/N two
  characters alpha/numeric)

• Lists the Valid Values for the DN

• Gives DP (Data Population) Rule to Help
  Identify the Correct Use of the Data Element

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Release 3 Dictionary
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Lets Get Started
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Rule 69L-56 Rule Section
Overview Claim Administrators must be
familiar with the requirements of this rule.
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EDI Rule 69L-56, F.A.C. was effective 1/7/2007
(Revised effective 5/17/2009) It requires all
insurers to implement the IAIABC Claims EDI
Release 3 electronic format.
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EDI Rule 69L-56, F.A.C.
This EDI Implementation applies to all required
form filings for all Dates of Injuries, and not
just those injuries that occur after the
Insurers EDI Implementation date. This includes
legacy claims.
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Rule 69L-56 Rule Section
Overview (Claim Administrators must be familiar
with the requirements of this rule.)
69L-56.001 Forms and Instructions 69L-56.002 Defi
nitions
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69L-56.100 Proof of Coverage (POC) Electronic
Reporting Requirements 69L-56.110 Technical
Requirements for POC EDI Transmissions 69L-56.20
0 Policy Cancellation or Non-renewal
Requirements 69L-56.210 Time Periods for Filing
Electronic Policy Information
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69L-56.300 Claims EDI Reporting Requirements and
Implementation Schedules 69L-56.301 Electronic
First Report of Injury or Illness 69L-56.3012
Electronic Notice of Denial and Rescinded
Denial 69L-56.3013 Electronic Periodic Claim
Cost Reports
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69L-56.304 Electronic Notice of Action or
Change, Including Change in Claims
Administration, Required by the Insurers
Primary Implementation Schedule
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69L-56.3045 Electronic Notice of Action or
Change, Suspensions, and Reinstatement of
Indemnity Benefits Required by the Insurers
Secondary Implementation Schedule The
Secondary Implementation Schedule is currently
not being used.
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69L-56.307 Electronic Cancellation of
Claim 69L-56.310 Technical Requirements for
Claims EDI Transmissions 69L-56.320 Claims EDI
Test to Production Status Requirements
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Insurers Responsibilities Where Third Party
Services Are Utilized
69L-56.500, F.A.C.
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Insurers Responsibilities Where Third Party
Services Are Utilized
If an insurer contracts with any third party (TPA
or vendor) or uses their software to send EDI
transactions to DWC, the insurer is still
responsible for the following
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Insurers Responsibilities Where Third Party
Services Are Utilized

• the timely filing of transactions required by
  this rule
• the processing of acknowledgements
• any penalties and fines that may result from a
  third partys untimely EDI filings.

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The former DWC paper forms previously filed with
the Division have been replaced by electronic
transactions
DWC-1 First Report Of Injury or Illness DWC-12
Notice of Denial DWC-13 Claim Cost Report DWC-4
Notice of Action/Change DWC-49 Aggregate Claims
Administration Change Report
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Rule 69L-56, F.A.C. identifies EDI filing
requirements (i.e., when a claim administrator
must file these EDI transactions with DWC). Rule
69L-3, F.A.C. identifies paper form copies still
required to be sent to other parties.
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• Read Rule 69L-56, F.A.C. in its entirety.
  http//www.myfloridacfo.com/wc/edi_clms.html

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The Most Important Thing Necessary to Begin
Filing Claims EDI is
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Accurately submitting and maintaining your EDI
Trading Partner Profile Documents
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EDI Trading Partner Profile Documents

• At least two (2) business days before sending
  the first test transmission, the Clm. Admin.
  shall send its current profile information to the
  DWC at claims.edi_at_myfloridacfo.com, using the
  following forms adopted in Rule 69L-56.001,
  F.A.C.

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EDI Trading Partner Profile Documents

• DFS-F5-DWC-EDI-1 EDI Trading Partner Profile
• DFS-F5-DWC-EDI-2 EDI Trading Partner Insurer /
  Claim Administrator ID List
• DFS-F5-DWC-EDI-2A EDI Trading Partner Claim
  Admin. Address List
• DFS-F5-DWC-EDI-3 EDI Transmission Profile
  Senders Specifications

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EDI Trading Partner Profile Documents

• If a form is incomplete and does not contain
  responses to all of the required fields in
  accordance with the instructions on the form, or
  does not match information in DWCs database, it
  will be returned.

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EDI Trading Partner Profile Documents

• A claim administrator can not begin testing with
  the DWC until the corrected form(s) is re-filed
  accurately.
• This is the number 1 problem that claim
  administrators encounter when beginning EDI
  testing.

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EDI Trading Partner Profile Documents

• All Changes to profile information shall be
  reported by sending revised Trading Partner
  Profile documents to DWC at claims.edi_at_myfloridacf
  o.com, at least two (2) business days prior to
  sending transactions containing revised
  profile-related information.

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EDI Trading Partner Profile Documents

• Failure to report changes to profile
  information may result in the rejection of an
  entire transmission or rejection
• of individual transaction(s).
• Changes in FEIN, address/postal codes or
  addition of an Insurer or new claims office
  requires Trading Partner documents to be
  updated.

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EDI Trading Partner Profile Documents

• An MTC 02 that is sent to report a change in
  the Insurer or Claim Admin. FEIN, Claim Admin.
  Postal Code, or Claim Admin. Claim Number due to
  the creation or elimination of a claims office
  location or subsidiary entity within the
  insurers organization does not replace the need
  to file revised TP Profile docs.

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EDI Trading Partner Profile Documents

• The MTC 02 would actually reject if it
  reported a different Claim Administrator
  FEIN/Postal Code that was not already in DWCs
  profile database.
• Therefore, before MTC 02 is filed to report,
  e.g., the transfer of a file to a new claims
  office location, revised TP Profile documents
  must be filed with the DWC to report the new
  location.

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EDI Trading Partner Profile Documents

• NOTE All 9 digits of the Trading Partners
  Postal Code should be sent in the Sender ID.
  This postal code must match either the Physical
  or Mailing Sender Address Postal Code, and should
  be a valid Home or Claims Office location for the
  company.

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Insurer/Claim Administrator ID List
DFS-F5-DWC-EDI-2
If the Sender/Trading Partner is an Insurer who
is also reporting for a TPA in its group, it is
very helpful to DWC if the Insurers listed on the
EDI-2 form are grouped. The Insurers that are
part of the corporate group should be listed
together, then the Insurers for which the TPA
will be the Claim Administrator should be listed
under the TPA name.

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EDI Trading Partner Profile Documents

• IMPORTANT If a 9-digit Postal Code is listed
  for a claims office location on the EDI 2-A form,
  the DWC profile will be established with all 9
  digits therefore all 9 digits must be sent on
  the transaction in order to match.
• If only 5 digits are listed on the form, the
  last 4 digits must be sent on the filing as
  blanks (spaces). If zeros are sent in the last 4
  digits, this will not match and will cause a
  rejection.

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EDI Trading Partner Profile Documents

• If two different claims office locations are in
  the same zip code area, the 9-digit Postal Code
  must be sent for each location on both the EDI-2A
  and the transaction.
• Postal code mis-matches between what is listed
  on the form vs. what is sent in the transaction
  is one of the top reasons a transaction rejects.

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EDI Trading Partner Profile Documents
There must be a one to one match between a
physical address and a mailing address for each
claims office location. The EDI 2-A must reflect
each of these unique combinations.
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EDI Trading Partner Profile Documents
For example If you have 5 physical locations on
Tab 1 of the EDI 2-A, then you must list 5
corresponding mailing locations on Tab 2 (even if
they are the same address). All FEINs for which
an address applies should be listed on each Tab.
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For New Trading Partners still in Test Status
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For NEW TPs still testing

• It is highly recommended you test using the
  actual program you will use in production, and to
  test with actual claim data.
• Some Insurers that tested with mock data
  experienced unanticipated errors not discovered
  in test when they started sending real claim
  data.

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For NEW TPs still testing

• DWC also recommends having claim reps who will
  actually handle the live production cases be
  involved in the testing process.
  
• This will ensure that claims staff are familiar
  with edits received, how to look up records in
  the data warehouse, and how to resolve the
  errors.

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For NEW TPs still testing

• After you are approved for production status, a
  30 day grace period will be applied for FROI
  filings that are accepted after their filing due
  date (See Rule 69L-24.0231(d), F.A.C.)

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69L-24.006(1)6.
After the completion of the 30 day grace period,
all electronic First Reports of Injury or Illness
must be assigned an Application Acknowledgement
Code of Transaction Accepted (TA) by the Division
within the required filing timeframes established
in subsections 69L-56.301(1) and (2), F.A.C., to
be considered timely filed.
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69L-24.006(1)6. This rule is often
misunderstood.

• In order to be eligible for the 30 day grace
  period, the transaction errors MUST be resolved
  within those 30 days, and RECEIVE A TA.
• It does not apply to filings received but not
  successfully filed/accepted during those first 30
  days .

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• If a rejection is not resolved and accepted
  within those first 30 days, penalties may
  apply in accordance with rule
  69L-56.301, F.A.C.

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• It is strongly recommended that First
  Report/Initial Payments transactions are
  triggered immediately upon mailing the first
  indemnity check, or upon decision to deny. This
  will allow for the maximum time possible to
  resolve any errors.

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• Ensure your IT staff or Vendor is prepared to
  react to programming problems discovered with
  your production data, and can implement solutions
  quickly during those initial 30 days.

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Production Trading Partners
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• Reminder Test files CAN be sent after a trading
  partner is approved for production however, it
  will only load to DWCs Test system. If a
  production file is accidentally sent with a T
  for Test, you will not receive credit for filing
  those claims until re-sent with a P for
  production.

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FL Claims EDI Webpage
Claims EDI
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FLs Claims EDI Webpage
http//www.myfloridacfo.com/wc/
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FLs Claims EDI Webpage
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The Claims EDI Webpage is your complete resource
for all of DWCs Claims EDI requirements
Scroll Down for much more info
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These are the Requirement Tables
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FLs Claims EDI Webpage
If you havent already, you should become
familiar with FLs requirement tables (including
updated supplement) to determine
When each
transaction must be sent (Event Table)
Data Elements required
for each transaction / MTC (Element Requirement
Table)
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FLs Claims EDI Webpage
(Contd) Review FLs requirement tables
(including updated supplement) to determine

Edits that will reject the record (Edit
Matrix) The Population Restrictions Tab of the
Edit Matrix will assist you in trouble shooting
why you received a particular error.
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FL Supplement Overview Tracks all monthly
additions or corrections to the requirement
tables.
Check the EDI website periodically for updates to
this Supplement.
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FLs Claims EDI Webpage

• The webpage also contains helpful resource
  documents including
• FL EDI Migration Strategies
• MTC Filing Instructions
• FL R3 Business Scenarios
• FL Quick Code Reference Guide
• MTC to Form Crosswalk
• Crosswalks of paper DWC Claims Forms to EDI Data
  Elements

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Helpful Resources
Other Resources
DWC Form Crosswalks
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Training
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Crosswalk of MTCs to DWC Forms
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The MTC to Form Crosswalk helps identify what
MTCs equate to which DWC forms.
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MTCs to DWC Forms
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MTCs to DWC Forms
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Not all MTC filing requirements set out in
Rule 69L-56, F.A.C., can be equated to a DWC
Form.See rule 69L-56 F.A.C. and FL Claims
EDI Event Table (also MTC Filing
Instructions) for a complete accounting of MTCs
required by FL.
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Acronyms (see FL Claims
EDI webpage for list)
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http//www.myfloridacfo.com/wc/edi_clms.html
EDI R3 Acronyms
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FL ACRONYMSExamples
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How Will EDI Errors Be Communicated to Claim
Administrators?
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The Division will acknowledge every EDI R3
transaction received with the standard EDI
Acknowledgement format AKC.
AKC Report
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The AKC acknowledgement will identify how many
transactions passed edits (TA -Transaction
Accepted) how many failed edits (TR
-Transaction Rejected) and the specific
error(s) that caused the transaction to
reject.
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FL does not use the TE Transaction Accepted
with Errors Acknowledgement Code however,
certain errors will display in the warehouse as
TA-FL and must be addressed by the claim
administrator.
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Acknowledgement results from the previous days
transmission(s) will be posted by 900 a.m. the
following morning in the EDI Data Warehouse.
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Transmissions received on or before 900 p.m.,
E.S.T., will be processed by DWC the same day the
transmission was sent. Transmissions will be
acknowledged the next calendar day (usually by
900 a.m. E.S.T.)
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Transmissions received after 900 p.m. EST will
be processed by DWC the following calendar day,

and will be acknowledged
the day after the transmission is processed.
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FL processes transmissions 7 days a week,
including holidays.
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If you need to confirm if or when a particular
filing or group of filings were received by the
Division, you can Search for Batches in the
Claims EDI Data Warehouse to determine when the
FROI and/or SROI batch was received (Click on the
Batch ID for batch details.
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If a transaction is improperly rejected by
the Division, the entire batch will be
re-processed and re-acknowledged using the ARC
Acknowledgement format. (see
the technical training PowerPoint
for more details on the
Acknowledgement Process)
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If DWC re-processes (re-loads) a transaction,
the Claim Administrator will receive credit for
the date the transaction was originally received
by the Division.
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FL provides EDI Claim Administrators the
capability of viewing all FROIs SROIs
received, via the on-line Claims EDI
Data Warehouse.
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The Claims EDI Data Warehouse will assist claim
administrators in resolving EDI errors faster,
and may also assist in
resolving issues with the Centralized
Performance System (CPS).
Claims EDI Warehouse
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More detailed information regarding the on-line
Claims EDI Data Warehouse is provided in the
Claims EDI Data Warehouse
Webinar/Training.
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A PowerPoint presentation on use of the Data
Warehouse is also posted on the Claims EDI web
page. Updated version will be posted soon.
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• Florida has made many corrections and
  adjustments to its EDI program to accommodate
  filing situations we did not initially
  anticipate.

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• FL may enhance its EDI program weekly or
  bi-weekly as needed. But if a new filing
  requirement will result in a rejection, we
  typically allow a 3 month implementation period
  before enforcing the new edit.

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After you have thoroughly investigated the error
(using DWC resource documents) and you still do
not understand the error...
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... please send an email to the Claims EDI Team
at claims.edi_at_myfloridacfo.com The EDI Team will
answer all questions via an email so that both
parties have a copy of the response for future
reference.
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By emailing your question, the EDI Team has the
opportunity to research the specific details of
the problem thoroughly. Phone calls do not allow
for adequate time for this research. We
appreciate your understanding.
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Reminder To avoid late filing penalties, the
Electronic First Report of Injury or Illness
(payment or denial) should be triggered
immediately upon the Claim Admin.s disposition
of the claim.
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This will allow time for correction of potential
filing errors and resubmission and subsequent
receipt/acceptance by the Division within the
filing due dates specified in Rule 69L-56, F.A.C.
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Hot Topic
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The following information is reported via Medical
EDI and should not be included in OBT (Other
Benefit Type Code) 370.

• Physician (includes physical therapy, functional
  capacity evaluations, and work hardening)
• Hospital
• Dental
• Pharmacy
• Durable Medical Expenses

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If you are currently reporting this information
under OBT 370, it should be corrected using the
following SROI 02 SA (amended) FN (amended)
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ALL Questions, either Business or Technical,
should be sent via email to claims.edi_at_myfloridacf
o.com This email address is copied to all
members of the EDI team. It is the quickest and
most efficient way for us to respond to your
concerns.
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Questions?
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