Rule Chapter 69L-56, F.A.C., is being amended to incorporate by reference the revised Form DFS-F5-DWC-EDI-1, “EDI Trading Partner Profile”, and the revised Form DFS-F5-DWC-EDI-4, “Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions”. ...

 

DEPARTMENT OF FINANCIAL SERVICES
Division of Worker's Compensation

RULE NO: RULE TITLE
69L-56.001: Forms and Instructions
69L-56.002: Definitions
69L-56.100: Proof of Coverage (POC) Electronic Reporting Requirements
69L-56.110: Technical Requirements for POC EDI Transmissions
69L-56.200: Policy Cancellation or Non-Renewal Requirements
69L-56.210: Time Periods for Filing Electronic Policy Information
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69L-56.3012: Electronic Notice of Denial and Rescinded Denial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
69L-56.304: Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer's Primary Implementation Schedule
69L-56.3045: Electronic Notice of Action or Change, Suspensions, and Reinstatement of Indemnity Benefits Required by Insurer's Secondary Implementation Schedule
69L-56.307: Electronic Cancellation of Claim
69L-56.310: Technical Requirements for Claims EDI Transmissions
69L-56.330: Electronic Formats for Reporting the Employee's 8th Day of Disability and the Claim Administrator's Knowledge of 8th Day of Disability
PURPOSE AND EFFECT: Rule Chapter 69L-56, F.A.C., is being amended to incorporate by reference the revised Form DFS-F5-DWC-EDI-1, “EDI Trading Partner Profile”, and the revised Form DFS-F5-DWC-EDI-4, “Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions”. The revised Florida Division of Workers’ Compensation Proof of Coverage (POC) Electronic Data Interchange (EDI) Implementation Manual (1/01/08), which contains revisions to the Element Requirement Table and Edit Matrix, and requires insurer reporting of total payroll and number of employees, is also incorporated by reference. The rule is also being amended to incorporate by reference the revised national standard International Association of Industrial Accident Boards and Commissions (IAIABC) EDI Implementation Guide for Proof of Coverage Release 2.1 (6/01/07) and the IAIABC EDI Release 3 Implementation Guide for Claims (1/01/08). Rule 69L-56.205, F.A.C., is being added to specify the insurer requirements of reporting proof of coverage information to the Division of Workers’ Compensation for a professional employer organization or employee leasing company and its client companies. The proposed rule also adds a definition regarding the meaning of “Cancellation/Non-Renewal Effective Date”, which clarifies that such an event occurs at 12:01 a.m. on that Transaction Set Type Effective Date reported to the Division of Workers’ Compensation, or as derived by the Division of Workers’ Compensation as determined in Rule 69L-56.200, F.A.C. Additionally, the proposed rule deletes redundant language from Rule 69L-56.100, F.A.C., changes the title to fully reflect the scope of the rule, and makes clerical revisions where necessary. Rule 69L-56.330, F.A.C., which has become obsolete, is to be repealed concurrently upon adoption of these proposed amendments.
SUMMARY: Amends the rule chapter to incorporate by reference revised forms, instructions, manuals and implementation guides for use by insurers in the electronic reporting of proof of coverage and claims information to the Division of Workers’ Compensation. Rule 69L-56.205, F.A.C., is added to specify insurer requirements of reporting proof of coverage information to the Division for a professional employer organization or employee leasing company and its client companies. Also, adds a definition for “Cancellation/Non-Renewal Date”, deletes redundant language from Rule 69L-56.100, F.A.C., and changes the rule chapter’s title. Rule 69L-56.330, F.A.C., which has become obsolete, is to be repealed concurrently upon adoption of the proposed amendments.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 440.185(7), 440.42(3), 440.591, 440.593(5), 627.4133(4) FS.
LAW IMPLEMENTED: 440.185(7), (9), 440.42(3), 440.593, 627.4133(4) FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Wednesday, January 21, 2009, 10:00 a.m.
PLACE: 104J Hartman Building, 2012 Capital Circle S.E., Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Linda Yon, EDI Coordinator, Bureau of Data Quality and Collection, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4226, phone [phone] or [e-mail].
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this program, please advise the Department at least 5 calendar days before the program by contacting the person listed above.

THE FULL TEXT OF THE PROPOSED RULE IS:

ELECTRONIC DATA INTERCHANGE (EDI) TECHNICAL REQUIREMENTS FOR PROOF OF COVERAGE AND CLAIMS (NON-MEDICAL)

69L-56.001 Forms and Instructions.

The following forms are incorporated herein by reference and adopted for use in filing Proof of Coverage (POC) and Claims (non-medical) Electronic Data Interchange (EDI) transactions to the Division. All of the forms may be obtained from the Division of Workers’ Compensation at its website, http://www.myfloridcfo.com/WC/edi_clms.html http:// www.fldfs.com/wc/edi.html.

(1) DFS-F5-DWC-EDI-1, “EDI Trading Partner Profile” (1/01/2008 10/01/2006).

(2) through (4) No change.

(5) DFS-F5-DWC-EDI-4, “Secure Socket Layer (SSL)/File Transfer Protocol (FTP) Instructions” (1/01/2008 10/01/2006).

Specific Authority 440.591, 440.593(5), FS. Law Implemented 440.593, FS. History–New 3-5-02, Formerly 38F-56.001, 4L-56.001, Amended 5-29-05, 1-7-07,_________.

 

69L-56.002 Definitions.

Unless otherwise defined in this section, definitions of data elements and terms used in this rule are defined in the Data Dictionary located in Section 6 of the “IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition”, and in the Data Dictionary located in Section 6 of the “IAIABC Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition”, and in the IAIABC “Glossary”, and in the IAIABC “Supplement” for both IAIABC products, all of which are incorporated herein by reference. Copies of the IAIABC guides, supplements, and glossary may be obtained from the IAIABC’s website at, http://www.iaiabc.org, under “EDI” link, then “Implementation Guides” link www.iaiabc.org/edi/implementation.asp.

When used in this chapter, the following terms have the following meanings:

(1) through (6) No change.

(7) “Business day” means a day on which normal business is conducted by the State of Florida and excludes observed holidays as set out in Section 110.117(1), F.S. (see also State Holidays under http://dms.myflorida.com/human_resource_support/human_resource_management/for_state_hr_practitionershttp://www.myflorida.com/myflorida/government/policies/holidays.html).

(8) No change.

(9) “Cancellation/Non-Renewal Effective Date” means the Transaction Set Type Effective Date as defined in the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07, for a cancellation or non-renewal of any workers’ compensation insurance policy, contract of insurance or renewal; and shall be effective at 12:01 a.m. on the Transaction Set Type Effective Date reported to the Division, or the Cancellation/Non-Renewal Effective Date derived by the Division as determined in Rule 69L-56.200, F.A.C.

(10)(9) “Catastrophic Event” means the occurrence of an event outside the control of an insurer, claim administrator, or third party vendor, such as a telecommunications failure due to a natural disaster or act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent an insurer, claim administrator, or third party vendor from meeting the filing requirements of Chapter 440, F.S., and this rule. Programming errors, systems malfunctions, or electronic data interchange failures that are not the direct result of a catastrophic event are not considered to be a catastrophic event as defined in this rule.

(11)(10) “Claim Administrator” means any insurer, service company/third party administrator, self-serviced self-insured employer or fund, or managing general agent, responsible for adjusting workers’ compensation claims, that is electronically sending its data directly to the Division.

(12)(11) “Claim Administrator Primary Address”, “Claim Administrator Secondary Address”, “Claim Administrator City”, “Claim Administrator State Code”, and “Claim Administrator Postal Code” comprise the address associated with the physical location of the claims office at which a workers’ compensation claim is being adjusted.

(13)(12) “Claim Administrator Alternate Postal Code” means the zip code associated with the Claim Administrator’s mailing address established for receiving mail on behalf of the claims office at which a workers’ compensation claim is being adjusted.

(14)(13) “Claim Type Code” means a code representing the current classification of the claim as either a “Lost Time/Indemnity Case” (Claim Type Code “I”), “Medical Only to Lost Time Case” (Claim Type Code “L”), “Became Medical Only Case” (Claim Type Code “B”) or “Medical Only Case” (Claim Type Code “M”).

(15) “Client Company” is as defined in subsection 468.520(6), F.S.

(16)(14) “Date of Maximum Medical Improvement” (MMI) means the date on which maximum medical improvement has been achieved with respect to all compensable medical or psychiatric conditions caused by a compensable injury or disease (i.e., overall MMI).

(17)(15) “Date Claim Administrator Had Knowledge of Lost Time” means the date the claim administrator was notified or became aware that the employee was disabled for eight (8) or more days and was entitled to indemnity benefits. If the claim administrator acquires a claim from another claim administrator and is filing the Electronic First Report of Injury or Illness with the Division, the “Date Claim Administrator Had Knowledge of Lost Time” shall be the date the acquiring claim administrator had knowledge of the employee’s 8th day of disability.

(18)(16) “Days” means calendar days, unless otherwise noted.

(19)(17) “Denied Case” means a “Full Denial” or “Partial Denial” case for which all indemnity benefits are initially denied by the claim administrator.

(20)(18) “Department” means the Department of Financial Services.

(21)(19) “Division” means the Division of Workers’ Compensation.

(22)(20) “Electronic Data Interchange” (EDI) means a computer-to-computer exchange of business transactions in a standardized electronic format.

(23)(21) “Electronic Form Equivalent” means information sent in Division-approved electronic formats as specified in this rule, instead of otherwise required paper documents. Electronic form equivalents may require additional information not required in Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213, 69L-3.025, F.A.C., for paper form filings. Electronic form equivalents do not include information sent by facsimile, file data attached to electronic mail, or computer-generated paper forms.

(24) “Employee leasing” is as defined in subsection 468.520(4), F.S.

(25) “Employee leasing company” is as defined in subsection 468.520(5), F.S.

(26) “Employee Leasing Policy Identification Code” is a code which identifies a policy written as an Employee leasing policy, and the type of leasing operation.

(27)(22) “Employer Paid Salary in Lieu of Compensation” means the employer paid the employee salary, wages, or other remuneration for a period of disability for which the insurer would have otherwise been obligated to pay indemnity benefits. This does not include the waiting week if the employee was not disabled for 22 or more days.

(28)(23) “File” or “Filed” means a transaction has been received by the Division and passes quality and structural edits and is assigned an Application Acknowledgement Code of “TA” (Transaction Accepted).

(29)(24) “FROI” means the First Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and is comprised of the First Report of Injury Record identified by Transaction Set ID “148” paired with the First Report of Injury Companion Record identified by Transaction Set ID “R21”. The “FROI” record layout (148/R21) is located in the Technical Documentation, Section 2, in the IAIABC EDI Implementation Guide for First, Subsequent, Acknowledgement Detail, Header, & Trailer Records, Release 3, January 1, 2008 June 1, 2006, which is incorporated herein by reference. A copy of the guide may be obtained from the IAIABC’s website at http://www.iaiabc.org, under “EDI” link, then “Implementation Guides” link http://iaiabc.org/edi/implementation. asp.

(30)(25) “Full Denial” means any case for which the claim administrator has denied liability for all workers’ compensation benefits (i.e., both indemnity and medical benefits). A “Full Denial” is represented by a FROI or SROI MTC 04 (Denial).

(31)(26) “Gross Weekly Amount” means the weekly amount payable for a specific Benefit Type and excludes the application of any Benefit Adjustments or Benefit Credits. The Gross Weekly Amount is usually equal to the Calculated Weekly Compensation Amount (a/k/a/ statutory compensation rate) except when the weekly rate for a Benefit Type is paid as a percentage of either the Calculated Weekly Compensation Amount (Comp Rate), Average Wage, or average temporary total disability benefits, such as for Permanent Total Supplemental Benefits, Death Benefits, and Impairment Income Benefits.

(32)(27) “Header Record” means the first record of a batch. The header record shall uniquely identify a sender, as well as the date and time a batch is prepared, and the transaction set within the batch.

(33)(28) “IAIABC” means the International Association of Industrial Accident Boards and Commissions (www.iaiabc.org), which is a professional trade association comprised of state workers’ compensation regulators and insurance representatives.

(34)(29) “Industry Code” means the 5 or 6-digit code that represents the nature of the employer’s business as published in the North American Industry Classification System (NAICS) 2002 Edition, hereby incorporated by reference. NAICS code information may be obtained by contacting the NAICS Association, 341 East James Circle, Sandy, Utah, 84070, or from the NAICS website at www.naics.com.

(35)(30) “Initial Date of Lost Time” means the employee’s eighth (8th) day of disability, i.e., the first day on which the employee sustains disability as defined in Section 440.02, F.S., after fulfilling the seven (7) day waiting week requirement in Section 440.12, F.S. The Initial Date of Lost Time does not mean the “Initial Date Disability Began”.

(36)(31) “Initial Disposition” means the first action taken by the claim administrator following its knowledge of an injury to accept or deny compensability of the claim and pay or deny benefits, including payment or denial of both indemnity and medical benefits, or denial of indemnity benefits only.

(37)(32) “Insurer” means an insurer as defined in Section 440.02, F.S.

(38)(33) “Insurer Code #” means the Division-assigned number for the insurer bearing the financial risk of the claim.

(39)(34) “Jurisdiction Designee Received Date” means the date on which a third party vendor received Proof of Coverage data from an insurer that is not submitting their electronic Proof of Coverage data directly with the Division. This date shall be used in place of the date the Division received electronic Proof of Coverage data for purposes of calculating the effective date of the cancellation or non-renewal, and timely filings of electronic Proof of Coverage data.

(40)(35) “Knowledge” or “Notification” means an entity’s earliest receipt of information, including by mail, telephone, facsimile, direct personal contact, or electronic submission.

(41)(36) “Lost Time/Indemnity Case” means a work-related injury or illness which causes the employee to be disabled for more than 7 calendar days, or for which indemnity benefits have been paid. A Lost Time/Indemnity Case shall also include: A case involving a compensable volunteer as defined in Section 440.02, F.S., where no indemnity benefits will be paid, but where the employee is disabled for more than 7 calendar days; a compensable death case pursuant to Section 440.16, F.S., for which there are no known or confirmed dependents; a case where a compensable injury results in disability of more than 7 calendar days where the “Employer Paid Salary in Lieu of Compensation” as defined in this section; a case for which indemnity benefits were paid prior to the date the claim administrator learned of a change in jurisdiction and filed SROI MTC S8 (Suspension, Jurisdiction Change); and a case where indemnity benefits were paid but subsequently suspended because the employee could not be located and the claim administrator filed SROI MTC S6 (Suspension, Claimant’s Whereabouts Unknown). The first 7 calendar days of disability do not have to occur consecutively, but are determined on a cumulative basis and can occur over a period of time. A “Lost Time/Indemnity Case” is represented by Claim Type Code “I” (Indemnity).

(42)(37) “Maintenance Type Code” (MTC) defines the specific purpose of individual claims transactions within the batch being sent, i.e., a code that represents the type of filing being sent electronically (For example: MTC IP = initial payment, MTC 04 = Total or Full Denial). MTC’s and data elements required by this rule may not exactly match paper claim forms and associated data reporting requirements set out in Rule Chapter 69L-3, F.A.C.

(43)(38) “Manual Classification Code” means the 4-digit code assigned by the National Council on Compensation Insurance (NCCI) for the particular occupation of the injured employee as documented in the NCCI Scopes™ Manual 2006 Edition, which is hereby incorporated by reference. A listing of Manual Classification Codes may be obtained by contacting NCCI’s Customer Service Center at 1(800)622-4123.

(44)(39) “Medical Only Case” means a work-related injury or illness which requires medical treatment for which charges will be incurred, but which does not cause the employee to be disabled for more than 7 calendar days. A “Medical Only Case” is represented by Claim Type “M” (Medical Only) and is limited to being reported on MTC 04 and PD filings where the claim was initially accepted as a Medical Only Case prior to the denial of indemnity benefits.

(45)(40) “Medical Only to Lost Time Case” means a work-related injury or illness which initially does not result in disability of more than 7 calendar days, but later results in disability of more than 7 days, where disability is either delayed and does not immediately follow the accident, or where one or more broken periods of disability occur within the first 7 days after disability has commenced and the combined disability periods eventually total more than 7 days. A “Medical Only to Lost Time Case” includes a case for which Impairment Income Benefits are the first and only indemnity benefits paid, or for which the initial payment of indemnity benefits is made in a lump sum for an award, advance, stipulated agreement or settlement. A “Medical Only to Lost Time Case” is represented by Claim Type Code “L” (Became Lost Time/Indemnity).

(46)(41) “Net Weekly Amount” means the weekly amount paid for an indemnity benefit such as temporary total benefits, impairment income benefits, etc., inclusive of any Benefit Adjustments or Benefit Credits being applied to the benefit type. The Net Weekly Amount equals the “Gross Weekly Amount” where no adjustments or credits are applied.

(47)(42) “Partial Denial” means a case where compensability is accepted but the claim administrator initially denies all indemnity benefits and only medical benefits will be paid; Partial Denial also means a case where a specific indemnity benefit(s) was previously paid but subsequently denied, either in whole or in part. A “Partial Denial” is represented by a SROI MTC “PD”.

(48)(43) “Payment Issue Date” for MTC “IP”(Initial Payment), and “PY” (Payment) means the date payment of a specific indemnity benefit corresponding to the MTC being reported left the control of the claim administrator (or the claim administrator’s legal representative if delivery is made by the legal representative) for delivery to the employee or the employee’s representative, whether by U.S. Postal Service or other delivery service, hand delivery, or transfer of electronic funds.  The Payment Issue Date 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.

(49)(44) “Permanent Impairment Percentage” means “Permanent Impairment” as defined in Section 440.02, F.S.

(50)(45) “Sender” means one of the following entities sending electronic filings to the Division:

(a) through (c) No change.

For Claims EDI filing purposes, “sender” does not include an entity acting as an intermediary for sending transmissions to the Division on behalf of an insurer or claim administrator where the sender is not the insurer or claim administrator handling the claim.

(51)(46) “SROI” means the Subsequent Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and includes the Subsequent Report Record identified by Transaction Set “A49” paired with the Subsequent Report Companion Record identified with Transaction Set ID “R22”. The “SROI” record layout (A49/R22) is located in the Technical Documentation, Section 2, in the IAIABC EDI Implementation Guide for First, Subsequent, Acknowledgement Detail, Header, & Trailer Records, Release 3, January 1, 2008 June 1, 2006, and Supplement, which is incorporated herein by reference. A copy of the guide may be obtained from the IAIABC’s website at http://www.iaiabc.org, under the “EDI” link, then “Implementation Guides” link http://iaiabc.org/edi/implementation.asp.

(52)(47) “Third Party Vendor” means an entity acting as a submission agent or vendor on behalf of an insurer, service company or third party administrator, which has been authorized to electronically send required data to the Division.

(53)(48) “Trading Partner” means an entity approved by the Division in accordance with Rules 69L-56.110, 69L-56.310 and 69L-56.320, F.A.C., to exchange data electronically with the Division.

(54)(49) “Trailer Record” means the last record that designates the end of a batch of transactions.  It shall provide a count of transactions contained within the batch, not including the header and trailer transactions.

(55)(50) “Transaction” is one or more records within a batch which communicates information representing an electronic form equivalent.

(56)(51) “Transaction Accepted Code TA” means an Application Acknowledgement Code returned by the Division on the acknowledgement transaction to represent that a transaction was received by the Division and passed required edits.

(57)(52) “Transaction Rejected Code TR” means an Application Acknowledgement Code returned by the Division on the acknowledgement transaction to represent that a transaction was received by the Division and did not pass required edits.

(58)(53) “Transmission” consists of one or more batches sent to or received by the Division or a trading partner.

(59)(54) “Triplicate Code” is a series of three two-digit numeric codes that define the specific purpose of individual records in a Proof of Coverage transmission, i.e., new policy, renewal, endorsement, cancellation or non-renewal. It is a combination of the Transaction Set Purpose Code, Transaction Set Type Code and Transaction Set Reason Code as defined in the Data Dictionary, Section 6 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/2007 10/01/06 Edition, which is incorporated herein by reference.  A copy of the guide may be found at http://www.iaiabc.org, under the “EDI” link, then “Implementation Guides” link http://iaiabc.org/edi/implementation.asp.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 3-5-02, Formerly 38F-56.002, 4L-56.002, Amended 5-29-05, 1-7-07,_________.

 

69L-56.100 Proof of Coverage (POC) Electronic Reporting Requirements.

(1) Effective March 1, 2002, every insurer authorized to insure employers in the State of Florida, except for individual self-insurers approved under Section 440.38, F.S., shall file policy information electronically to the Division rather than by filing on paper forms previously required.

Every insurer shall send to the department by electronic data interchange electronic policy information for Certificates of Insurance, Endorsements, Reinstatements, Cancellations and Non-Renewals pursuant to the filing time periods in Rule 69L-56.210, F.A.C., of this chapter.  Such policy information shall be sent in accordance with the “EDI Trading Partner Requirements” set forth in Sections 2 through 6 of the Florida Division of Workers’ Compensation Proof of Coverage Electronic Data Interchange (EDI) Implementation Manual, 1/01/2008 January 2005, which is incorporated herein by reference.  A copy of the manual may be obtained from the Division of Workers’ Compensation at its website, http://www.myfloridacfo.com/WC/edi_poc.html http://www.fldfs.com/wc/edi.html, or by sending a request to the Division of Workers’ Compensation, Bureau Office of Data Quality and & Collection, 200 East Gaines Street, Tallahassee, Florida 32399-4226. The Division will not accept an electronic transaction that fails to comply with the “EDI Trading Partner Requirements” in Sections 2 through 6 in this manual.  The insurer shall send electronic transmissions either directly to the Division or through a third party vendor.

Every insurer shall send to the Division by electronic data interchange electronic policy information for Certificates of Insurance, Endorsements, Reinstatements, Cancellations and Non-Renewals pursuant to the filing time periods in Rule 69L-56.210, F.A.C. Such policy information shall be sent in accordance with the “EDI Trading Partner Requirements” set forth in Section 2 through 6 of the Florida Division of Workers’ Compensation Proof of Coverage Electronic Data Interchange (EDI) Implementation Manual, July 2006, which is incorporated herein by reference. A copy of the manual may be obtained from the Division of Workers’ Compensation at its website, http://www.fldfs.com/wc/edi.html. The Division will not accept an electronic transaction that fails to comply with the “EDI Trading Partner Requirements” in Sections 2 through 6 in this manual. The insurer shall send electronic transmissions either directly to the Division or through a third party vendor.

(2) On or before April 2, 2007, all electronic form equivalents of Proof of Coverage data shall be sent in the Proof of Coverage formats adopted by the IAIABC and located in Section 2 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/2007 10/01/06 Edition.

(3)(a) At least one (1) business day before the insurer or third party vendor sends its first transmission to the Division, the insurer or third party vendor shall send to the Division in an email addressed to [e-mail] [e-mail], their profile information using the following forms adopted in Rule 69L-56.001, F.A.C.:

1. “EDI Trading Partner Profile,” DFS-F5-DWC-EDI-1 (1/01/2008 10/01/2006), and

2. “EDI Trading Partner Insurer/Claim Administrator ID List”, DFS-F5-DWC-EDI-2 (10/01/2006), and

3. “EDI Transmission Profile – Sender’s Specifications,” DFS-F5-DWC-EDI-3 (10/01/2006).

(b) The insurer or third party vendor shall report changes to its profile information to the Division at least one (1) business day before sending transactions containing new profile-related information.  The insurer or third party vendor shall report the new profile information by emailing a revised “EDI Trading Partner Profile”, DFS-F5-DWC-EDI-1 (1/01/2008 10/01/2006), and if applicable, the “EDI Trading Partner Insurer/Claim Administrator ID List”, DFS-F5-DWC-EDI-2 (10/01/2006), and if applicable, the “EDI Transmission Profile – Sender’s Specifications”, DFS-F5-DWC-EDI-3 (10/01/2006) to the Division at [e-mail] [e-mail].

(c) If the insurer suspends the use of a third party vendor and begins sending its electronic Proof of Coverage data directly to the Division, the insurer shall, at least one (1) business day prior to the effective date of this change, email a revised “EDI Transmission Profile – Sender’s Specifications,” DFS-F5-DWC-EDI-3 (10/01/2006), to the Division at [e-mail] [e-mail].

(d) If the insurer changes third party vendors, the insurer shall, at least one (1) business day prior to the effective date of the change, send an email to the Division at [e-mail] [e-mail] to report the name of the new vendor and effective date on which POC transactions will be sent by the new vendor.

(e) Insurers or third party vendors that experience a catastrophic event resulting in the insurer’s failure to meet the filing requirements of this rule, shall submit a written or electronic request to the Division for approval to submit required electronic form equivalents in an alternative filing timeline. The request shall be sent to the Division within 15 business days after the catastrophic event. The request shall contain a detailed explanation of the nature of the event, date of occurrence, and measures being taken to resume electronic submission. The insurer or third party vendor shall also provide an estimated date by which electronic submission of affected EDI filings will be resumed.  Approval to submit in an alternative filing timeline shall be granted by the Division if a catastrophic event prevents electronic submission. The approval must be obtained from the Division’s

Specific Authority 440.185(7), 440.591, 440.593(5), FS. Law Implemented 440.185(7), 440.593, FS. History–New 3-5-02, Formerly 38F-56.100, 4L-56.100, Amended 5-29-05, 1-7-07, ________.

 

69L-56.110 Technical Requirements for POC EDI Transmissions.

(1) In order to send Proof of Coverage data electronically to the Division, the insurer or third party vendor shall complete the testing requirements set forth in Section 1 of the Florida Division of Workers’ Compensation Proof of Coverage Electronic Data Interchange (EDI) Implementation Manual, 1/01/08 July 2006.  Each transmission for Test or Production purposes shall be in the PC1-Insured Record format and PC2-Employer Record format located in Section 2 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition and Supplement.

(2) Each transmission shall contain the following as set forth in Section 2 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition:

(a) through (c) No change.

(3) No change.

(a) through (d) No change.

(4) POC EDI transmissions may be sent on a daily basis, and shall be sent via secured File Transfer Protocol (FTP). Effective June 1, 2005, electronic transmissions of Proof of Coverage data required pursuant to this rule, shall be sent to the Division using Secure Socket Layer/File Transfer Protocol (SSL/FTP) in accordance with instructions on Form DFS-F5-DWC-EDI-4 (1/01/2008 10/01/2006).

(5) No change.

(6) Transmissions shall be sent using the flat file PC1 and PC2 formats located in Section of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition and Supplement.

(7) No change.

(8) All insurers or third party vendors shall have the capability to receive and process the Division’s POC EDI Acknowledgement Transaction (AKP), described in Section 2 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition and Supplement.  The Division will also send, when applicable, a re-acknowledgment transaction (ACR) to identify an EDI filing previously acknowledged with Application Acknowledgement Code “TR” (Transaction Rejected) due to improper processing, that was subsequently re-processed by the Division and re-assigned an Application Acknowledgement Code of “TA” (Transaction Accepted).  The claim administrator shall have the option of processing re-acknowledgement transactions.

(9) The definitions established in Section 6 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition and Supplement, shall be utilized when reporting data elements to the Division.

(10) The insurer or third party vendor shall send the PC1 and PC2 transactions required in Rule 69L-56.210, F.A.C., in accordance with the information appearing in the “Sub Type Code” column in the “Proof of Coverage Transaction Overview” document, located in Section 4 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition. If the PC2 record is required and is rejected by the Division, both the PC1 and PC2 records shall be re-sent together in the same transmission.  The Division will not “hold” a PC1 record in anticipation of the return of a corrected corresponding PC2 record.

(11) through (12) No change.

Specific Authority 440.591, 440.593(5), FS. Law Implemented 440.593, FS. History–New 3-5-02, Formerly 38F-56.110, 4L-56.110, Amended 5-29-05, 1-7-07,_______.

 

69L-56.200 Policy Cancellation or Non-Renewal Requirements.

(1) Except for cancellation for nonpayment of premium or failure to pay deductible, or cancellation or non-renewal at the request of the insured, an insurer shall not cancel or non-renew any workers’ compensation insurance policy, contract of insurance, or renewal until at least 30 days have elapsed after the insurer has electronically filed a cancellation or non-renewal with the Division, either directly or through a third party vendor. When an insurer files an electronic cancellation or non-renewal directly with the Division for any reason other than non-payment of premium or failure to pay deductible or when cancellation or non-renewal is requested by the insured, the 30-day notice period (Cancellation/Non-Renewal Effective Date) shall be calculated from the first day following the date on which the electronic cancellation or non-renewal was filed with the Division.  If the insurer files an electronic cancellation or non-renewal through a third party vendor for any reason other than non-payment of premium or failure to pay deductible, or when cancellation or non-renewal is requested by the insured, the 30-day notice period (Cancellation/Non-Renewal Effective Date) shall be calculated from the first day following the “Jurisdiction Designee Received Date”.

(2)(a) For any workers’ compensation insurance policy, contract of insurance, or renewal with a policy effective date prior to October 1, 2003, an insurer shall not cancel or non-renew the policy for non-payment of premium or failure to pay deductible until and unless 30 days have elapsed after the insurer has electronically filed a cancellation or non-renewal with the Division, either directly or through a third party vendor.  When an insurer files an electronic cancellation or non-renewal directly with the Division, the 30-day notice period (Cancellation/Non-Renewal Effective Date) shall be calculated from the first day following the date on which the electronic cancellation or non-renewal was filed with the Division.  If the insurer files an electronic cancellation or non-renewal through a third party vendor, the 30-day notice period (Cancellation/Non-Renewal Effective Date) shall be calculated from the first day following the “Jurisdiction Designee Received Date”.

(b) No change.

(3) If an insured requests cancellation or non-renewal of any workers’ compensation insurance policy, contract of insurance or renewal, the cancellation or non-renewal shall be effective on the date the insurer sends the cancellation or non-renewal to the insured. Notification to the Division is not required to cancel or non-renew a workers’ compensation insurance policy, contract of insurance, or renewal when cancellation or non-renewal is requested by the insured.  However, the insurer shall advise the Division of the Cancellation/Non-Renewal Effective Date cancellation or non-renewal requested by the insured in accordance with the electronic filing time periods for policy information set out in subsection 69L-56.210(7), F.A.C.

(4) No change.

Specific Authority 440.185(7), 440.42(3), 440.591, 440.593(5), 627.4133(4) FS. Law Implemented 440.185(7), 440.42(3), 440.593, 627.4133(4) FS. History–New 5-29-05, Amended 1-7-07,_________.

 

69L-56.205 Policy Reporting Requirements for Employee Leasing Companies.

(1) For any workers’ compensation insurance policy, contract of insurance or renewal written for an Employee leasing company or clients of an Employee leasing company, with a policy effective date on or after July 1, 2009, the insurer shall electronically file any workers’ compensation insurance policy, contract of insurance, or renewal pursuant to the requirements set forth in Rule 69L-56.210, F.A.C., and report one of the Employee Leasing Policy Idenitification Codes shown below from Section 6 of the IAIABC EDI Implementation Guide for Proof of Coverage:  Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 Edition and Supplement:

(a) Employee Leasing Policy Identification Code (2) – identifies an Employee leasing policy for leased workers of multiple client companies.  The non-leased workers of the Employee leasing company may also be covered under this policy.  The insured name reported shall be the name of the Employee leasing company and shall be reported on the IAIABC POC Release 2.1 Insured Record (PC1).  The client names reported shall be the legal business name of each client company, and shall not be preceded with the name of the Employee leasing company and shall be reported on the IAIABC POC Release 2.1 Employer Record(s) (PC2).

1. If an Employee leasing company policy is reported with the Employee Leasing Policy Identification Code (2), an Employee leasing policy for leased workers of multiple client companies, the Insurer shall report the addition of client companies to the policy in accordance with subsection 69L-56.210(2), F.A.C., using Triplicate Codes 00-31-54, 00-31-87 or 00-31-86.

2. If an Employee leasing company policy is reported with Employee Leasing Policy Identification Code (2), an Employee leasing policy for leased workers of multiple client companies, the Insurer shall report the deletion of client companies from the policy in accordance with subsection 69L-56.210(2), F.A.C., using Triplicate Codes 00-33-56 or 00-33-87.

3. Cancellation or non-renewal of the entire policy for Employee Leasing Policy Identification Code (2) shall be reported in accordance with Rule 69L-56.200, F.A.C.

(b)1. Employee Leasing Policy Identification Code (3) – identifies an Employee leasing policy for non-leased workers of the Employee leasing company. The insured name reported shall be the legal business name of the Employee leasing company and shall be reported on the IAIABC POC Release 2.1 Insured Record (PC1).

2. Cancellation or non-renewal of a policy for Employee Leasing Policy Identification Code (3) shall be reported in accordance with Rule 69L-56.200, F.A.C.

(c)1. Employee Leasing Policy Identification Code (4) – identifies a Client company policy for leased workers of the Client company.  The insured name reported shall be the name of the Client company and shall not be preceded with the name of the Employee leasing company and shall be reported on the IAIABC POC Release 2.1 Insured Record (PC1).

2. Cancellation or non-renewal of a policy for the Employee Leasing Policy Identification Code (4) shall be reported in accordance with Rule 69L-56.200, F.A.C.

(d)1. Employee Leasing Policy Identification Code (5) – identifies an Employee leasing policy for leased workers of a single client company.  The insured name reported shall be the name of the Employee leasing company and shall be reported on the IAIABC POC Release 2.1 Insured Record (PC1).  The client name reported shall be the legal business name of the client company, and shall not be preceded with the name of the Employee leasing company, and shall be reported on the IAIABC POC Release 2.1 Employer Record(s) (PC2).

2. Cancellation or non-renewal of a policy for Employee Leasing Policy Identification Code (5) shall be reported in accordance with Rule 69L-56.200, F.A.C.

Specific Authority 440.185(7), 440.42(3), 440.591, 440.593(5) FS.  Law Implemented 440.185(7), 440.42(3), 440.593 FS. History–New _________.

 

69L-56.210 Time Periods for Filing Electronic Policy Information.

Pursuant to subsection 440.593(1), F.S., the Division may establish different deadlines for filing required reports electronically than are otherwise required when reporting information by other means.  Accordingly, notwithstanding the deadlines for filing policy information by other means as set forth in subsection 440.185(7), F.S., an insurer, other than an individual self-insurer approved under Section 440.38, F.S., must electronically file the following information in accordance with the provisions of this rule, and shall have received an Application Acknowledgement Code of “TA” (Transaction Accepted) by the Division within the following deadlines:

(1) through (6) No change.

(7) No later than ten days after the cancellation or non-renewal of any workers' compensation insurance policy, contract of insurance, or renewal for which an insured has requested cancellation or non-renewal, the insurer shall send the electronic cancellation or non-renewal to the Division.  The electronic cancellation or non-renewal shall be represented by Triplicate Codes containing Transaction Set Type Codes “42” & “60”, with the exception of Triplicate Code “00-60-64”, pursuant to the “Transaction Overview” document, located in Section 4 of the IAIABC EDI Implementation Guide for Proof of Coverage: Insured, Employer, Header, Trailer & Acknowledgement Records, Release 2.1, 6/01/07 10/01/06 Edition and Supplement.

(8) No change.

Specific Authority 440.185(7), 440.42(3), 440.591, 440.593(5), 627.4133(4) FS. Law Implemented 440.185(7), (9), 440.42(3), 440.593, 627.4133(4) FS. History–New 5-29-05, Amended 1-7-07,________.

 

69L-56.300 Claims EDI Reporting Requirements and Implementation Schedules.

(1)(a) On or before the implementation schedules set out in paragraphs (3)(a) and (b) of this section, every insurer shall file claims information for all “Lost Time/Indemnity,” “Medical Only to Lost Time,” and “Denied” cases via electronic data interchange (EDI) pursuant to paragraph (d) of this section, rather than by submitting paper forms otherwise required in Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213 and 69L-3.025, F.A.C. The insurer shall file the electronic form equivalent of the First Report of Injury or Illness, Notice of Denial, Claim Cost Report, Notice of Action/Change, and Aggregate Claims Administration Change Report adopted in Rule 69L-3.025, F.A.C., pursuant to the requirements and timeframes set out in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304 and 69L-56.3045, F.A.C., and in accordance with the “FL Claims EDI R3 Trading Partner Filing Specifications” contained in Section 1 of the “Florida Division of Workers’ Compensation Claims Electronic Data Interchange (EDI) R3 Implementation Manual, September 2006” and “Supplement,” incorporated herein by reference, and hereafter referred to as the “FL Claims EDI Implementation Manual.”  A copy of the FL Claims EDI Implementation Manual may be obtained from the Division of Workers’ Compensation at its website, http://www.myfloridacfo.com/WC/edi_clms.html www.fldfs.com/WC/edi_clms.html.

(b) through (c) No change.

(d) The claim administrator shall report the Claims EDI filings required in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045 and 69L-56.307, F.A.C., using the First Report of Injury (FROI) and Subsequent Report of Injury (SROI) electronic record layouts adopted by the International Association of Industrial Accident Boards and Commissions (IAIABC). A sample of the FROI, which consists of the 148 and companion R21 records, and a sample of the SROI, which consists of the A49 and companion R22 records, are located in Section 2, “Technical Documentation” of the “IAIABC EDI Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition” and “Supplement,” incorporated herein by reference, and hereafter referred to as the IAIABC Claims EDI Release 3 Implementation Guide. A copy of this guide may be obtained from the IAIABC at its website, http://www.iaiabc.org, under “EDI” link, then “Implementation Guides” link http://www.iaiabc.org/edi/implementation.asp.

1. The claim administrator shall send the FROI (148/R21), SROI (A49/R22), and combination FROI and SROI records with the Maintenance Type Code (MTC) or MTC combinations specified in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045 and 69L-56.307, F.A.C., to represent the Claims EDI Filing being sent to the Division (Example: FROI MTC 04 = Total Denial of an Electronic First Report of Injury or Illness; SROI MTC FN = Electronic Final Claim Cost Report; FROI MTC 00 with SROI MTC IP = Electronic First Report of Injury or Illness where the Initial Payment is made by claim administrator.)

(e) through (k) No change.

(l) Claim administrators who, directly or through its third party vendor, experience a catastrophic event resulting in the insurer’s failure to meet the filing requirements of this rule, shall submit a written or electronic request to the Division for approval to submit required electronic form equivalents in an alternative filing timeline. The request shall be sent to the Division within 15 business days after the catastrophic event. The request shall contain a detailed explanation of the nature of the event, date of occurrence, and measures being taken to resume electronic submission. The claim administrator shall also provide an estimated date by which electronic submission of affected EDI filings will be resumed. Approval to submit in an alternative filing timeline shall be granted by the Division if a catastrophic event prevents electronic submission. The approval must be obtained from the Division’s Bureau Office of Data Quality and Collection, 200 E. Gaines Street, Tallahassee, Florida 32399-4226, or via email at [e-mail] [e-mail]. If approved, the electronic form equivalents that were due to be filed during the time the claim administrator was unable to file due to a catastrophic event, shall be sent with Late Reason Code “LB” (Late notification/payment due to a Natural Disaster) or “LC” (Late notification/payment due to an act of Terrorism).

(m) No change.

(2) Trading Partner Profile Documents:

(a) At least two (2) business days prior to sending its first test transmission to the Division, the claim administrator shall send to the Division in an email addressed to [e-mail] [e-mail], the claim administrator’s current profile information using the following forms adopted in Rule 69L-56.001, F.A.C.:

1. “EDI Trading Partner Profile,” DFS-F5-DWC-EDI-1 (1/01/2008 10/01/2006), and

2. through 4. No change.

Claim administrators filing Electronic First Reports of Injury or Illness or Electronic Claim Cost Reports on a voluntary basis using the IAIABC Release 1 standard formats shall re-file their profile information with the Division using the forms in subparagraphs (2)(a)1.-4. above, even if the claim administrator’s profile information has not changed since previously reported to the Division.

(b) The claim administrator shall report changes to its profile information required on the forms listed in subparagraphs (2)(a)1.-4. above, at least two (2) business days prior to sending transactions containing revised profile-related information to the Division. The insurer or its claim administrator shall report revisions to its profile information by emailing to the Division at [e-mail] [e-mail], a revised “EDI Trading Partner Profile,” DFS-F5-DWC-EDI-1 (1/01/2008 10/02/2006), 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), and if applicable, a revised “EDI Transmission Profile – Sender’s Specifications”, DFS-F5-DWC-EDI-3 (10/01/2006). Failure by the claim administrator to report changes to its trading partner profile information using the forms adopted in this rule, including changes to the Submitter ID (i.e., Trading Partner FEIN/Postal Code on the Header Record), may result in the rejection of an entire transmission or individual transaction(s) containing profile information that is different from that reported on profile documents previously filed with the Division by the claim administrator.

(c) If the insurer or its claim administrator contracts with a new third party vendor, the insurer or its claim administrator shall, at least two (2) business days prior to the effective date of the change in vendors, send an email to the Division at [e-mail] [e-mail] to report the name of the new vendor and effective date on which Claims EDI transactions will be sent via the new vendor.

(3) Claims EDI Implementation Schedules:

(a) through (d) No change.

(e) After the conclusion of the three month time period specified in paragraph 69L-56.300(3)(d), F.A.C., above, if the claim administrator is unable to receive an Application Acknowledgement Code of “TA” from the Division for an electronic form equivalent required by this rule chapter, and the claim administrator needs to meet the reporting requirements of this rule, the claim administrator shall submit an e-mail to the Division at [e-mail] [e-mail] to request approval to alternatively file a DWC form pursuant to Rules 69L-3.0045, 69L-3.0091, 69L-3.012, 69L-3.016, 69L-3.0213 and 69L-3.025, F.A.C., in lieu of the electronic form equivalent. The request shall include the following information: Claim Administrator Name and FEIN, Employee Name, Employee ID Number (Social Security Number or Division Assigned Number), Date of Injury, Claim Administrator File Number, Maintenance Type Code (MTC), Date Transmission Sent for the MTC(s) attempted unsuccessfully, the DWC form requesting to be filed (i.e., DWC-13), and an explanation of the reasons electronic submission failed. If the Division approves the claim administrator’s request to send a DWC form in lieu of the electronic form equivalent, all subsequent filings due for the claim shall be sent via EDI; the claim administrator shall not file additional DWC forms for the claim unless the claim administrator has received advance approval from the Division.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended________.

 

69L-56.301 Electronic First Report of Injury or Illness.

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 claims information otherwise reported on Form DFS-F2-DWC-1 adopted in Rules 69L-3.0045 and 69L-3.025, F.A.C. Pursuant to subsection 440.593(1), F.S., the Division may establish different deadlines for filing required reports electronically than are otherwise required when reporting information by other means. Accordingly, notwithstanding the deadlines for filing the injury report by other means as set forth in subsection 440.185(2), F.S., the insurer or its claim administrator shall send to the Division the electronic form equivalent of the First Report of Injury or Illness for the following cases, and by the following filing time periods:

(1) Initial Payment for “Lost Time Case” or “Medical Only to Lost Time Case” (FROI MTC 00 with SROI MTC IP, EP, CD, VE, or PY as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition):

(a) through (b) No change.

(2) “Denied Case”:

(FROI MTC 04, or SROI MTC PD with applicable FROI MTC as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition).

(a) through (c) No change.

(3) through (8) No change.

(9) If the employee does not have or wish to provide a Social Security Number, the claim administrator shall contact the Division by following the instructions provided on the Division’s website: http://www.myfloridacfo.com/WC/organization/odqc.html www.fldfs.com/WC/organizationodqc.html (under Records Management – Division-Assigned Numbers) and obtain a Division-assigned number. Upon receipt of the employee’s Social Security Number, the claim administrator shall file MTC 02 (Change) and provide the employee and employer with Form DFS-F2-DWC-4, pursuant to Rule 69L-3.025, F.A.C.

(10) No change.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

69L-56.3012 Electronic Notice of Denial and Rescinded Denial.

(FROI/SROI MTC 04, SROI MTC PD as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition)

On or before the compliance date established in the insurer’s Primary Implementation Schedule set forth in paragraph 69L-56.301(3)(a), F.A.C., the insurer shall file the electronic form equivalent for the denial information otherwise reported on Form DFS-F2-DWC-12, adopted in Rules 69L-3.012 and 69L-3.025, F.A.C. The claim administrator shall send to the Division an Electronic Notice of Denial to report the reason for the denial of indemnity benefits for the following types of denial notices, and by the following time periods:

(1) through (7) No change.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

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, 2008 June 1, 2006 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) through (6) No change.

Specific Authority 440.591, 440.593(5), FS. Law Implemented 440.593, FS. History–New 1-7-07, Amended_________.

 

69L-56.304 Electronic Notice of Action or Change, Including Change in Claims Administration, Required by the Insurer’s Primary Implementation Schedule.

(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, 2008 June 1, 2006 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. through 11. No change.

(b) No change.

(2) No change.

(a) through (b) No change.

(c) No change.

1. through 6. No change.

7. No change.

a.i. 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).

b.ii. 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.

(d) No change.

1. through 2. No change.

(3) through (5) No change.

(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 10/01/2006), 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.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

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, 2008 June 1, 2006 Edition)

(1) through (6) No change.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

69L-56.307 Electronic Cancellation of Claim.

(FROI MTC 01 as found in the IAIABC Implementation Guide for Claims: First, Subsequent, Header, Trailer & Acknowledgement Detail Records, Release 3, January 1, 2008 June 1, 2006 Edition)

(1) through (2) No change.

Specific Authority 440.591, 440.593(5) FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

69L-56.310 Technical Requirements for Claims EDI Transmissions.

(1) Insurers shall send Claims EDI Filings required in Rules 69L-56.301, 69L-56.3012, 69L-56.3013, 69L-56.304, 69L-56.3045, 69L-56.307 and 69L-56.330, F.A.C., to the Division using only the following transmission methods:

(a) No change.

(b) Secure Socket Layer/File Transfer Protocol (SSL/FTP) in accordance with instructions on Form DFS-F5-DWC-EDI-4 (1/01/2008 10/1/2006).

(2) No change.

(3)(a) through (c) No change.

(d) Header records shall include the following information:

1. through 2. No change.

3. Sender Identifier. The Sender Identifier (Sender ID) shall consist of the claim administrator’s FEIN and Postal Code as reported on Form DFS-F5-DWC-EDI-3 (10/01/2006 01/01/2005), EDI Transmission Profile – Sender’s Specifications.

(4) through (11) No change.

Specific Authority 440.591, 440.593 FS. Law Implemented 440.593 FS. History–New 1-7-07, Amended_________.

 

69L-56.330 Electronic Formats for Reporting the Employee’s 8th Day of Disability and the Claim Administrator’s Knowledge of the 8th Day of Disability.

(1) Until required by this rule to report Claims EDI filings using the IAIABC Release 3 standard, if a claim administrator is voluntarily reporting Claims EDI information using the IAIABC EDI Release 1 standard and reports the electronic First Report of Injury or Illness with Claim Type “L” (“Became Lost Time/Indemnity”, a.k.a., Medical Only to Lost Time), the claim administrator shall report the employee’s 8th day of disability and the claim administrator’s knowledge of the 8th day of disability at the same time the electronic form equivalent of Form DFS-F2-DWC-1 is required to be sent to the Division as specified in Rule 69L-56.301, F.A.C., using any of the electronic formats approved by the Division and adopted by reference in this rule.

(2) If the initial payment of benefits is for Impairment Income Benefits or settlement agreement or order for indemnity benefits, or follows a total or partial denial, the claim administrator is not required to electronically report the employee’s 8th day of disability and the claim administrator’s knowledge of 8th day of disability.

(3) The claim administrator shall utilize the electronic format, “Electronic Supplement to the First Report of Injury (DWC-1) Transaction (January 2005)”, from the Division’s web site at www.fldfs.com/wc/edi.html, or the “8th Day of Disability For EDI Submitters” database located at www.fldfs.com/wc/ to report the employee’s 8th day of disability and the claim administrator’s knowledge of the 8th day of disability required in Rule Chapter 69L-3, F.A.C.

Specific Authority 440.591, 440.593 FS. Law Implemented 440.593 FS. History–New 5-29-05, Amended 1-7-07, Repealed_________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Linda Yon, EDI Coordinator, Bureau of Data Quality and Collection, Division of Workers’ Compensation

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Alex Sink, Chief Financial Officer, Department of Financial Services

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: September 15, 2008

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: October 31, 2008