Florida Regulations 69L-56.320: Claims EDI Test and Production Status Requirements
Current as of: 2024 | Check for updates
|
Other versions
(1) Prior to sending an initial test transmission, the claim administrator shall file the EDI Trading Partner forms required in subsection 69L-56.300(2), F.A.C. If a form is incomplete and does not contain responses to all of the required fields in accordance with the form instructions, testing with the Division will not commence until the corrected form(s) is re-filed with the Division.
(2) If the claim administrator has contracted with a vendor to send Claims EDI filings on its behalf to the Division, the claim administrator shall comply with the testing requirements in this section before being approved for production status, even if the vendor has been previously approved by the Division for production status with another client.
(3) During the Claims EDI testing period and until the claim administrator is approved for production status for sending the required electronic form equivalents required by this rule, the claim administrator shall continue to file Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13 and DFS-F2-DWC-4 and DFS-F2-DWC-49 in accordance with Rules 69L-56.4011, 69L-56.404, 69L-56.4012, 69L-56.4013 and 69L-3.025, F.A.C.
(4) The claim administrator shall send test files in the correct IAIABC Release 3 formats specified in Section 2, Technical Documentation, of the IAIABC Claims EDI Release 3 Implementation Guide, and comply with transmission requirements set out in Rule 69L-56.310, F.AC.
(5) The insurer or claim administrator shall indicate the Maintenance Type Codes (MTC’s) it will be sending, if not all MTC’s will be initially tested at the same time (e.g., MTC’s not required until the insurer’s Secondary Implementation Schedule). The claim administrator shall file a revised Form DFS-F5-DWC-EDI-3, EDI Transmission Profile – Sender Specifications, to report any new MTC’s that will be added during the test to production periods.
(6) The claim administrator shall also indicate on its Form DFS-F5-DWC-EDI-3, Transmission Profile – Sender Specifications, the frequency with which files will be sent to the Division, i.e., daily, weekly. Test files shall consist of Claims EDI Filings that correspond with Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13, and DFS-F2-DWC-4 adopted in Rules 69L-3.025, F.A.C., that were previously mailed to the Division at least one week prior to the date the test transmission containing the corresponding Electronic First Report of Injury or Illness, Electronic Notice of Denial, Electronic Periodic Claim Cost Report, and Electronic Notice of Action or Change, Suspension, and Reinstatement of Indemnity Benefits information is sent to the Division. If the claim administrator is unable to transmit test files on a daily or weekly basis due to a low volume of actual claim filings being mailed to the Division during the specified testing frequency, the claim administrator may create and send “”mock”” paper and electronic filings for Claims EDI testing purposes. The claim administrator shall clearly mark any mock paper filings as an “”EDI Test Filing”” and fax the mock paper filings to the Division’s Claims EDI Team at (850)488-3453.
(7) Data element values sent on the test Claims EDI filings shall match values reported on the corresponding paper form filing. If differences are detected and cited in a written parallel analysis report issued to the claim administrator by the Division, the claim administrator shall confirm if the electronic version contained the accurate data, or otherwise provide an explanation for the discrepancy. The claim administrator shall investigate and reconcile its database as necessary in conjunction with data errors identified during the test period(s).
(8) The claim administrator shall send the following minimum number of Claims EDI filings during the test period(s), of which 90% of each of the required categories specified in paragraphs (5)(a) through (f) of this section shall receive an Application Acknowledgement Code of “”TA””:
(a) Ten (10) Electronic First Report of Injury or Illness filings utilizing at least two of each of the following required FROI/SROI MTC combinations: 00/IP, 00/EP, and 00/PY. MTC’s 00/CD, 00/VE, and AU/AP may be optionally included in the testing period. The claim administrator shall send one of the two required MTC 00/IP filings with Claim Type “”I”” and the other required MTC 00/IP filing with Claim Type “”L.””
(b) Five (5) Electronic Denied First Report of Injury or Illness filings utilizing at least one FROI MTC 04 (Full Denial) and one FROI MTC 00 with SROI PD (Partial Denial). The Electronic First Report of Injury or Illness shall include the applicable Full Denial Reason Code(s) and Partial Denial Code with Denial Reason Narrative, to report the Electronic Notice of Denial information.
(c) Ten (10) Electronic Periodic Claim Cost filings utilizing at least two each of the following SROI MTC’s: SA or FN. A corresponding paper or Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing MTC SA or FN.
(d) Five (5) Electronic Notice of Denial filings (post-EDI DWC-1) utilizing at least one each of the following SROI MTC’s: MTC 04 and PD. (Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing these EDI filings.)
(e) Five (5) Electronic Notice of Action or Change transactions based on electronic filings required in the insurer’s Primary Implementation Schedule for the initial testing period if not all MTC’s will be implemented by the insurer during its Primary Implementation Schedule, utilizing either FROI or SROI MTC 02 (Change). A corresponding paper or Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing these EDI filings with the Division.
(f) Five (5) of the following Electronic Notice of Action or Changes, Suspension and Reinstatement of Indemnity Benefits filings required in the insurer’s Secondary Implementation Schedule utilizing at least two MTC 02 filings, one of which shall report a change in the Average Wage with no change to the Net Weekly Amount and one MTC 02 that reports a Benefit Redistribution. The claim administrator shall also send at least one each of the following MTC’s: S1-S8 (Suspensions); RB (Reinstatement); CA (Change in Amount), CB (Change in Benefit Type).
(9) To be approved for production status:
(a) The claim administrator shall achieve a 90% acceptance rate for Claims EDI Filings sent during the test period(s), i.e., 90% of all test Claims EDI Filings shall be accepted and assigned an Application Acknowledgement Code “”TA”” (Transaction Accepted), and 10% or less of all Claims EDI filings shall be assigned an Application Acknowledgement Code “”TR”” (Transaction Rejected); and,
(b) The claim administrator must achieve a 95% accuracy rate for correctly reporting the following data elements:
1. Benefit Payment Issue Date and Payment Issue Date (represents the date payment was mailed to the employee); and,
2. Employee SSN and Date of Injury (unless Form DFS-FS-DWC-4, Notice of Action/Change adopted in Rules 69L-56.404 and 69L-3.025, F.A.C., was filed to report a change in Employee SSN and Date of Injury that explains the different value sent on the test EDI filing compared to the value sent on the prior paper or EDI filing); and,
3. Benefit Type reported on the Division paper form promulgated under Rules 69L-56.4011, 69L-56.404, 69L-56.4012, 69L-56.4013, and 69L-3.025, F.A.C., compared to the test Electronic First Report of Injury or Illness filing; and,
4. Initial Date of Lost Time; and,
5. Date Claim Administrator Had Knowledge of Lost Time; and,
6. Any penalties and/or Interest reported on the prior paper filing compared to the test Electronic First Report of Injury or Illness; and,
(c) The claim administrator has responded to all parallel pilot analysis reports issued during the test period(s).
(10) The claim administrator shall send a minimum of two transmissions containing the test MTC’s pursuant to subsection (8) of this section for evaluation by the Division before the claim administrator will be approved for production status.
Rulemaking Authority 440.591, 440.593(5) FS. Law Implemented Florida Statutes § 440.593. History-New 1-7-07.
(3) During the Claims EDI testing period and until the claim administrator is approved for production status for sending the required electronic form equivalents required by this rule, the claim administrator shall continue to file Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13 and DFS-F2-DWC-4 and DFS-F2-DWC-49 in accordance with Rules 69L-56.4011, 69L-56.404, 69L-56.4012, 69L-56.4013 and 69L-3.025, F.A.C.
(4) The claim administrator shall send test files in the correct IAIABC Release 3 formats specified in Section 2, Technical Documentation, of the IAIABC Claims EDI Release 3 Implementation Guide, and comply with transmission requirements set out in Rule 69L-56.310, F.AC.
(5) The insurer or claim administrator shall indicate the Maintenance Type Codes (MTC’s) it will be sending, if not all MTC’s will be initially tested at the same time (e.g., MTC’s not required until the insurer’s Secondary Implementation Schedule). The claim administrator shall file a revised Form DFS-F5-DWC-EDI-3, EDI Transmission Profile – Sender Specifications, to report any new MTC’s that will be added during the test to production periods.
(6) The claim administrator shall also indicate on its Form DFS-F5-DWC-EDI-3, Transmission Profile – Sender Specifications, the frequency with which files will be sent to the Division, i.e., daily, weekly. Test files shall consist of Claims EDI Filings that correspond with Forms DFS-F2-DWC-1, DFS-F2-DWC-12, DFS-F2-DWC-13, and DFS-F2-DWC-4 adopted in Rules 69L-3.025, F.A.C., that were previously mailed to the Division at least one week prior to the date the test transmission containing the corresponding Electronic First Report of Injury or Illness, Electronic Notice of Denial, Electronic Periodic Claim Cost Report, and Electronic Notice of Action or Change, Suspension, and Reinstatement of Indemnity Benefits information is sent to the Division. If the claim administrator is unable to transmit test files on a daily or weekly basis due to a low volume of actual claim filings being mailed to the Division during the specified testing frequency, the claim administrator may create and send “”mock”” paper and electronic filings for Claims EDI testing purposes. The claim administrator shall clearly mark any mock paper filings as an “”EDI Test Filing”” and fax the mock paper filings to the Division’s Claims EDI Team at (850)488-3453.
(7) Data element values sent on the test Claims EDI filings shall match values reported on the corresponding paper form filing. If differences are detected and cited in a written parallel analysis report issued to the claim administrator by the Division, the claim administrator shall confirm if the electronic version contained the accurate data, or otherwise provide an explanation for the discrepancy. The claim administrator shall investigate and reconcile its database as necessary in conjunction with data errors identified during the test period(s).
(8) The claim administrator shall send the following minimum number of Claims EDI filings during the test period(s), of which 90% of each of the required categories specified in paragraphs (5)(a) through (f) of this section shall receive an Application Acknowledgement Code of “”TA””:
(a) Ten (10) Electronic First Report of Injury or Illness filings utilizing at least two of each of the following required FROI/SROI MTC combinations: 00/IP, 00/EP, and 00/PY. MTC’s 00/CD, 00/VE, and AU/AP may be optionally included in the testing period. The claim administrator shall send one of the two required MTC 00/IP filings with Claim Type “”I”” and the other required MTC 00/IP filing with Claim Type “”L.””
(b) Five (5) Electronic Denied First Report of Injury or Illness filings utilizing at least one FROI MTC 04 (Full Denial) and one FROI MTC 00 with SROI PD (Partial Denial). The Electronic First Report of Injury or Illness shall include the applicable Full Denial Reason Code(s) and Partial Denial Code with Denial Reason Narrative, to report the Electronic Notice of Denial information.
(c) Ten (10) Electronic Periodic Claim Cost filings utilizing at least two each of the following SROI MTC’s: SA or FN. A corresponding paper or Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing MTC SA or FN.
(d) Five (5) Electronic Notice of Denial filings (post-EDI DWC-1) utilizing at least one each of the following SROI MTC’s: MTC 04 and PD. (Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing these EDI filings.)
(e) Five (5) Electronic Notice of Action or Change transactions based on electronic filings required in the insurer’s Primary Implementation Schedule for the initial testing period if not all MTC’s will be implemented by the insurer during its Primary Implementation Schedule, utilizing either FROI or SROI MTC 02 (Change). A corresponding paper or Electronic First Report of Injury or Illness must have been previously accepted in test or production status before testing these EDI filings with the Division.
(f) Five (5) of the following Electronic Notice of Action or Changes, Suspension and Reinstatement of Indemnity Benefits filings required in the insurer’s Secondary Implementation Schedule utilizing at least two MTC 02 filings, one of which shall report a change in the Average Wage with no change to the Net Weekly Amount and one MTC 02 that reports a Benefit Redistribution. The claim administrator shall also send at least one each of the following MTC’s: S1-S8 (Suspensions); RB (Reinstatement); CA (Change in Amount), CB (Change in Benefit Type).
(9) To be approved for production status:
(a) The claim administrator shall achieve a 90% acceptance rate for Claims EDI Filings sent during the test period(s), i.e., 90% of all test Claims EDI Filings shall be accepted and assigned an Application Acknowledgement Code “”TA”” (Transaction Accepted), and 10% or less of all Claims EDI filings shall be assigned an Application Acknowledgement Code “”TR”” (Transaction Rejected); and,
(b) The claim administrator must achieve a 95% accuracy rate for correctly reporting the following data elements:
1. Benefit Payment Issue Date and Payment Issue Date (represents the date payment was mailed to the employee); and,
2. Employee SSN and Date of Injury (unless Form DFS-FS-DWC-4, Notice of Action/Change adopted in Rules 69L-56.404 and 69L-3.025, F.A.C., was filed to report a change in Employee SSN and Date of Injury that explains the different value sent on the test EDI filing compared to the value sent on the prior paper or EDI filing); and,
3. Benefit Type reported on the Division paper form promulgated under Rules 69L-56.4011, 69L-56.404, 69L-56.4012, 69L-56.4013, and 69L-3.025, F.A.C., compared to the test Electronic First Report of Injury or Illness filing; and,
4. Initial Date of Lost Time; and,
5. Date Claim Administrator Had Knowledge of Lost Time; and,
6. Any penalties and/or Interest reported on the prior paper filing compared to the test Electronic First Report of Injury or Illness; and,
(c) The claim administrator has responded to all parallel pilot analysis reports issued during the test period(s).
(10) The claim administrator shall send a minimum of two transmissions containing the test MTC’s pursuant to subsection (8) of this section for evaluation by the Division before the claim administrator will be approved for production status.
Rulemaking Authority 440.591, 440.593(5) FS. Law Implemented Florida Statutes § 440.593. History-New 1-7-07.