FL Claims EDI Release 3 Training

Report
Florida Division of Workers’
Compensation
Claims EDI
Basic Overview
2013
1
Presenter:
Tonya Granger
Administrator, Claims & POC EDI Team
Bureau of Data Quality and Collection
FL Division of Workers’ Compensation
2
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.
3
Rule Chapter 69L-56
of the
Florida Administrative Code
is the EDI Rule for
Proof of Coverage and
Claims (non-medical)
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.
So Here’s A Little
Background On
EDI …
On a National level, in 1990 the
IAIABC spearheaded a program
to utilize the concept of EDI for
Workers’ Compensation data.
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.
8
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!
9
Developing an Electronic
Standard
Bringing Together the Important
Participants
Jurisdictions
TPA’s
Carriers
Vendors
Developing a National Standard
through the IAIABC EDI
Development Committees was a
process that required “give” and
“take” from all participants.
The end result is a national standard
format for the reporting of workers’
compensation data electronically.
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.
13
Where can you find
the IAIABC R3
Implementation
Guide & Codes?
www.iaiabc.org
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.
17
The Release 3 Claims
Implementation Guide can be
purchased for $195 from the
IAIABC’s 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.
www.iaiabc.org
18
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.
19
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.
20
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.
21
STANDARD USAGE FOR ALL PRODUCTS
Glossary
Glossary
The purpose of the glossary is to
acquaint the reader with easy-tounderstand definitions of workers'
compensation terms.
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.
Glossary
Alphabetical
by term
Glossary
Terms that are specific to
approved data elements will
be found in the Data
Dictionary sections of the
individual Implementation
Guides.
Acronyms
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 don’t understand what
the acronyms stand for.
ACRONYM
Examples:
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
Release 3
Combined
Business & Technical
Data Dictionary
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.
34
Release
3 Data
Dictionary
Section 6 in the
Implementation
Guide
Data Element Dictionary
 Identifies the Data Number
(DN)
 Gives the Definition of the Data
Element
 Gives the Last Revision Date
of the Data Element
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
Release 3 Dictionary
Let’s Get
Started…
39
Rule 69L-56
Rule Section Overview
Claim Administrators must be
familiar with the requirements of
this rule.
40
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.
41
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 Insurer’s EDI
Implementation date. This
includes legacy claims.
42
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 Definitions
43
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
44
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
45
69L-56.304 Electronic Notice of Action or
Change, Including Change in Claims
Administration, Required by the
Insurer’s Primary Implementation
Schedule
46
69L-56.3045 Electronic Notice of Action
or Change, Suspensions, and
Reinstatement of Indemnity Benefits
Required by the Insurer’s Secondary
Implementation Schedule
** The Secondary Implementation
Schedule is currently not being used.
47
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
48
Insurer’s Responsibilities
Where Third Party
Services Are Utilized
69L-56.500, F.A.C.
Insurer’s 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…
50
Insurer’s 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
party’s untimely EDI filings.
51
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
52
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.
53
Read Rule 69L-56, F.A.C.
in it’s entirety.
http://www.myfloridacfo.com/wc/edi_clms.html
54
The Most
Important Thing
Necessary to
Begin Filing
Claims EDI is…
55
…Accurately
submitting and
maintaining your
EDI Trading Partner
Profile
Documents
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
[email protected], using
the following forms adopted in Rule
69L-56.001, F.A.C.:
57
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 –
Sender’s Specifications
58
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
DWC’s database, it will be
returned.
59
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 administrator’s encounter
when beginning EDI testing.
60
EDI Trading Partner
Profile Documents
All Changes to profile information
shall be reported by sending revised
Trading Partner Profile documents to
DWC at [email protected],
at least two (2) business days prior to
sending transactions containing
revised profile-related information.
61
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.
62
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
insurer’s organization does not replace
the need to file revised TP Profile docs.
63
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 DWC’s 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.
64
EDI Trading Partner
Profile Documents
NOTE: All 9 digits of the Trading
Partner’s 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.
65
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.
66
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.67
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.
68
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.
69
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.
70
For
New Trading Partners
still in Test Status…
71
For NEW TP’s 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.
72
For NEW TP’s 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.
73
For NEW TP’s 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.)
74
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.
75
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 .
76
 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.
77
 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.
78
 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.
79
Production Trading
Partners…
80
Reminder: Test files CAN be
sent after a trading partner is
approved for production; however,
it will only load to DWC’s 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.
81
FL Claims EDI
Webpage
Claims
EDI
FL’s Claims EDI Webpage
http://www.myfloridacfo.com/wc/
83
FL’s Claims EDI Webpage
84
The Claims EDI Webpage is your complete
resource for all of DWC’s “Claims EDI”
requirements
Scroll
Down
for
much
more
info
85
86
These are the
Requirement
Tables
87
FL’s Claims EDI Webpage
If you haven’t already, you should
become familiar with FL’s 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)
88
FL’s Claims EDI Webpage
(Cont’d)…
Review FL’s 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.
89
FL Supplement Overview:
Tracks all monthly additions or corrections to
the requirement tables.
Check the EDI website periodically
for updates to this Supplement.
90
FL’s 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
91
Helpful Resources
Other
Resources
DWC Form
Crosswalks
92
Training
93
Crosswalk of
MTC’s
to DWC Forms
94
The MTC to
Form
Crosswalk
helps identify
what MTC’s
equate to
which DWC
forms.
95
MTC’s to DWC Forms
96
MTC’s to DWC Forms
97
 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
MTC’s required by FL.
98
Acronyms
(see FL Claims EDI
webpage for list)
http://www.myfloridacfo.com/wc/edi_clms.html
EDI R3
Acronyms
100
FL ACRONYMS
Examples:
101
How Will EDI Errors
Be Communicated to
Claim Administrators?
102
The Division will
acknowledge every EDI
R3 transaction received
with the standard EDI
Acknowledgement format:
‘AKC’.
103
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.
104
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.
105
Acknowledgement results
from the previous day’s
transmission(s) will be
posted by 9:00 a.m. the
following morning in the
EDI Data Warehouse.
106
Transmissions received on or
before 9:00 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 9:00 a.m. E.S.T.)
107
Transmissions received after
9:00 p.m. EST will be processed
by DWC the following calendar
day,
and will be acknowledged the
day after the transmission is
processed.
108
FL processes
transmissions 7
days a week,
including holidays.
109
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.
110
111
112
If a transaction is improperly
rejected by the Division, the entire
batch will be re-processed and reacknowledged using the ‘ARC’
Acknowledgement format.
(see the technical training
PowerPoint for more
details on the
Acknowledgement Process)
113
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.
114
FL provides EDI Claim
Administrators the capability
of viewing all FROI’s & SROI’s
received, via the on-line
Claims EDI
Data Warehouse.
115
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
116
More detailed information
regarding the on-line Claims EDI
Data Warehouse is provided in
the Claims EDI Data Warehouse
Webinar/Training.
Claims
EDI
Warehouse
117
A PowerPoint
presentation
on use of the
Data
Warehouse is
also posted
on the Claims
EDI web
page.
**Updated
version will
be posted
soon.
118
 Florida has made many
corrections and adjustments
to its EDI program to
accommodate filing situations
we did not initially anticipate.
119
 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.
120
After you have thoroughly
investigated the error (using
DWC resource documents) and
you still do not understand the
error...
121
... please send an email to the
Claims EDI Team at
[email protected]
The EDI Team will answer all
questions via an email so that both
parties have a copy of the
response for future
reference.
122
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.
123
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.
124
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.
125
Hot
Topic
126
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
127
If you are currently reporting this
information under OBT 370, it should
be corrected using the following:
SROI 02
SA (amended)
FN (amended)
128
ALL Questions, either Business or
Technical, should be sent via email to
[email protected]
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.
129
Questions?
130
131

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