69L-56.3013. Electronic Periodic Claim Cost Reports

(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-3.016 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-24.021, 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).

Rulemaking Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended 5-17-09.