Florida Division of Workers’ Compensation Claims EDI Release 3

1

Florida Division of Workers’ Florida Division of Workers’ Compensation Compensation

Claims EDI Claims EDI Release 3 Release 3

Training Training April 27 & April 27 & 28,28, 2010 2010

2

Presenter:Presenter:

Linda Yon Linda Yon

Sr. Management Analyst Supv.Sr. Management Analyst Supv.

Bureau of Data Quality and Bureau of Data Quality and

Collection Division of Collection Division of

Workers’ Compensation (DWC)Workers’ Compensation (DWC)

3

Additional DWC Additional DWC Staff:Staff:

Tonya GrangerTonya Granger – – Administrator, Administrator, Claims & Claims & POC EDI TeamPOC EDI Team Kim WileyKim Wiley – Claims EDI – Claims EDI Project Project ManagerManagerKaren KubieKaren Kubie –Claims EDI –Claims EDI Operations Review Operations Review SpecialistSpecialist

4

Margaret ForsmanMargaret Forsman – Lead – Lead

Claims Claims EDI Business EDI Business

AnalystAnalyst

Laura CotnerLaura Cotner - Claims EDI - Claims EDI

& POC & POC SpecialistSpecialist

Debra LeeDebra Lee – Claims EDI – Claims EDI

Specialist Specialist

Additional DWC Additional DWC StaffStaff

5

Vickie FieldsVickie Fields - - Claims EDI Claims EDI Analyst Analyst

Amanda LoveAmanda Love - - Claims EDI Claims EDI

Analyst Analyst

Janice YoungbloodJanice Youngblood – Claims – Claims EDI and POC EDI and POC Consultant/ProgrammerConsultant/Programmer

Additional DWC Additional DWC StaffStaff

6

This training is new and This training is new and assumes you have assumes you have received prior received prior instruction on the basics instruction on the basics of the Clams EDI R3 of the Clams EDI R3 process, and have a process, and have a familiarity with the familiarity with the various IAIABC various IAIABC transactions (MTC’s) transactions (MTC’s) and FL’s requirements and FL’s requirements tables. tables.

7

We will be highlighting We will be highlighting transactions (MTC’s) that transactions (MTC’s) that typically occur in the life typically occur in the life of a claim, with more in of a claim, with more in depth discussion geared depth discussion geared towards towards helping you helping you avoid various filing avoid various filing errorserrors we are seeing we are seeing on a consistent on a consistent basis.basis.

8

HELPFUL HINTS, Caveats HELPFUL HINTS, Caveats and Tips for Successful and Tips for Successful FilingFiling will be will be interspersed interspersed throughout the throughout the presentation, as well presentation, as well as many other reminders as many other reminders and “Lessons Learned”. and “Lessons Learned”.

Please feel free to share Please feel free to share your own experiences and your own experiences and lessons learned if we do lessons learned if we do not address them first.not address them first.

9

Training will also include:Training will also include:

Emphasis on Ensuring Emphasis on Ensuring Data Data Quality;Quality;

Review of some Basic EDI Review of some Basic EDI Training information; Training information;

VVarious EDI scenarios and arious EDI scenarios and interactive interactive

‘training exercises’;‘training exercises’;

10

We recognize that your We recognize that your company’s system or your company’s system or your

vendor’s software vendor’s software application may use application may use

different data element different data element names and look names and look

significantly different significantly different compared to the sample compared to the sample record layouts/scenarios record layouts/scenarios we will be using during we will be using during

the training.the training.

11

This training also includes:This training also includes:

How to investigate How to investigate errors and errors and utilize EDI utilize EDI resources (e.g., Edit resources (e.g., Edit Matrix, Element Req. Table) Matrix, Element Req. Table) in in order to understand order to understand errors and errors and make necessary make necessary corrections; andcorrections; and

Review of NEW features Review of NEW features in the in the Claims EDI Claims EDI Data Data Warehouse.Warehouse.

12

Towards the end of Towards the end of training and time training and time permitting (after break permitting (after break tomorrow afternoon), tomorrow afternoon), we will address:we will address:

Acquired Claims and Acquired Claims and

Testing requirements Testing requirements for those who may for those who may not yet be in not yet be in production status.production status.

13

Please turn all cells and Please turn all cells and pagers to vibrate and step pagers to vibrate and step outside if you must take a outside if you must take a call.call.

Please refrain from Please refrain from engaging in sidebar engaging in sidebar conversations with conversations with other members of your other members of your group as it can be group as it can be veryvery distractingdistracting to others. to others.

14

We encourage you We encourage you to raise your hand to raise your hand and ask lots of and ask lots of questions. questions.

15

If you prefer, you If you prefer, you can can write your write your question on an question on an

index card and drop it in index card and drop it in the basket at break, lunch the basket at break, lunch or end of the day. Please or end of the day. Please be as specific as possible. be as specific as possible.

We will try to read and We will try to read and answer as many answer as many

questions as we can. questions as we can.

16

So Let’s So Let’s Get It Get It

Started…Started…

17

The Most The Most Important Important Component Component of Claims EDI of Claims EDI is…is…

18

Data Data QualityQuality

19

Data quality is Data quality is essentialessential and has and has become more become more significant and significant and necessary with necessary with EDI EDI reporting.reporting.

20

Incoming data will Incoming data will undergo undergo rigorousrigorous edits as edits as documented in our Edit documented in our Edit Matrix!Matrix!

Pay close attention to the Pay close attention to the accuracy of your data. accuracy of your data.

Research and resolve Research and resolve errors timely. errors timely.

21

Claims Managers & Claims Managers & Supervisors -Supervisors -

Ensure there is sufficient Ensure there is sufficient staff dedicated to staff dedicated to reviewing the results of reviewing the results of each day’s transmissions each day’s transmissions and immediately resolve and immediately resolve issues with any issues with any transactions that reject transactions that reject (TR).(TR).

22

DWCDWC will be will be conducting conducting on-on-going data quality reviewsgoing data quality reviews to identify ‘suspect’ data to identify ‘suspect’ data elements, which appear to elements, which appear to be inaccurate and are not be inaccurate and are not currently being edited by currently being edited by the R3 Claims EDI the R3 Claims EDI program edits. (e.g., program edits. (e.g., Nmbr Days Worked/WkNmbr Days Worked/Wk sent as “7”.) sent as “7”.)

23

DWC Auditors will also DWC Auditors will also be conducting be conducting data data validation reviews validation reviews to to confirm the data confirm the data submitted via EDI is submitted via EDI is accurate and consistent accurate and consistent based on information in based on information in the Claim the Claim Administrator’s file.Administrator’s file.

24

Examples of EDI data reviewed Examples of EDI data reviewed on audit for accuracy on audit for accuracy include:include:

Date Reported to Employer/Claim Date Reported to Employer/Claim Admin.Admin.

Initial Date Disability BeganInitial Date Disability Began

Initial Date of Lost Time (8Initial Date of Lost Time (8thth day) & day) & Knowledge ofKnowledge of Lost Time (88thth day) day)

Claim TypeClaim Type

Empr Paid Salary Ind./Salary Empr Paid Salary Ind./Salary Through DateThrough Date

25

How to How to Improve Data Improve Data

QualityQuality

26

To improve data To improve data quality:quality:

An ‘external’ Claims An ‘external’ Claims EDI Data Warehouse EDI Data Warehouse was created to help our was created to help our trading partners review trading partners review and resolve and resolve errors fastererrors faster (including filing issues (including filing issues impacting CPS.) impacting CPS.)

27

The The Claims EDI Data Claims EDI Data WarehouseWarehouse contains all contains all of the filings / of the filings / transactions received by transactions received by DWCDWC and their associated and their associated

processing processing outcomes outcomes (TA, TR, TA-FL).(TA, TR, TA-FL).

Claims Claims EDI EDI

WarehouWarehousese

28

For Clarification on All Filing For Clarification on All Filing Errors:Errors:

PLEASE refer to the PLEASE refer to the Claims Claims EDI Data WarehouseEDI Data Warehouse, which , which usually contains an error usually contains an error message that is much message that is much easier to understand than easier to understand than what you might see in your what you might see in your system (also data element system (also data element in question is highlighted.) in question is highlighted.)

29

ErrorsErrors cannot cannot be corrected via the be corrected via the Data Warehouse. You stillData Warehouse. You still have to have to correct and re-send the necessary correct and re-send the necessary transaction to resolve a rejection. transaction to resolve a rejection.

Unless the Division processed a Unless the Division processed a filing improperly, the filing filing improperly, the filing outcomes and statistics presented outcomes and statistics presented in the warehouse in the warehouse will not be will not be changed.changed.

30

Claims Managers & Claims Managers & Supervisors -Supervisors -

Ensure that all staff Ensure that all staff handling EDI and emailing handling EDI and emailing the Claims EDI Team has the Claims EDI Team has access and familiarity with access and familiarity with the Claims EDI Data the Claims EDI Data Warehouse. Warehouse.

This is the first place the This is the first place the EDI Team will go to help EDI Team will go to help you with your filing issues.you with your filing issues.

31

Monitor filing outcomes Monitor filing outcomes via the Claims EDI Data via the Claims EDI Data Warehouse Warehouse by 9:00 a.m. by 9:00 a.m. the following morningthe following morning to correct and quickly to correct and quickly re-file any rejected re-file any rejected transactions.transactions.

32

Do notDo not continue to continue to resend a rejected resend a rejected transaction if you have transaction if you have not changed any data…not changed any data… it it will only reject again, and will only reject again, and cost your company cost your company money if you pay by the money if you pay by the transactiontransaction……

33

… … Additionally, this Additionally, this practice will practice will negatively impact negatively impact your Report Cardyour Report Card by by over-inflating your over-inflating your counts and counts and percentage of rejected percentage of rejected filings.filings.

34

Do Do notnot alter any alter any factual factual data or data or Benefit/Payment Benefit/Payment information in an information in an attempt to attempt to pass an pass an edit. edit.

35

If a transaction is If a transaction is improperly rejected by improperly rejected by DWC, the entire batch will DWC, the entire batch will be re-processed and re-be re-processed and re-acknowledged using the acknowledged using the ‘ARC’ Acknowledgement ‘ARC’ Acknowledgement format.format.

See the See the ‘Technical Training’‘Technical Training’ PowerPoint slides PowerPoint slides for more details for more details on the Acknowledgement on the Acknowledgement Process.Process.

Reminder from Basic EDI Reminder from Basic EDI Training:Training:

36

If the Division re-If the Division re-processes (re-processes (re-loads) an electronic loads) an electronic filing/MTC, you will filing/MTC, you will receive credit for the receive credit for the date the filing/MTC date the filing/MTC was originally received was originally received by the Division.by the Division.


37

Communicate filing Communicate filing issues with your IT issues with your IT staff or vendor staff or vendor

so they can so they can address address

potential potential programming issues programming issues and implement and implement solutions quickly. solutions quickly.

38

More Improvements:More Improvements:

FL has made many FL has made many corrections and corrections and adjustments to its Claims adjustments to its Claims EDI program to EDI program to accommodate filing accommodate filing situations we did not situations we did not initially anticipate. initially anticipate.

Revised documentation of Revised documentation of edits changes, etc. were edits changes, etc. were last posted to DWC’s web last posted to DWC’s web site on 3/8/2010.site on 3/8/2010.

39

FL may potentially FL may potentially enhance its Claims EDI enhance its Claims EDI program every two program every two weeks as needed weeks as needed (e.g., to (e.g., to relax an edit). relax an edit).

However, if a new filing However, if a new filing requirement will result requirement will result in a rejection, we in a rejection, we typically allow a typically allow a 3 3 month implementation month implementation periodperiod before enforcing before enforcing a new edit.a new edit.

40

Monthly advisory email Monthly advisory email notifications are sent re: notifications are sent re: changes to edits or changes to edits or data elements or filing data elements or filing requirements. requirements.

If you are not already a If you are not already a recipient of these emails, recipient of these emails, a revised EDI-1 should be a revised EDI-1 should be filed to add you as a filed to add you as a Business Contact.Business Contact.

41

For Additional Clarification on For Additional Clarification on Filing Errors:Filing Errors:

PLEASE also utilize the PLEASE also utilize the resources available on resources available on the DWC’s Claims EDI Web the DWC’s Claims EDI Web site for assistance in site for assistance in understanding errors, understanding errors, including the including the Edits MatrixEdits Matrix and and Element Requirement TableElement Requirement Table..

42

Reminder from Basic EDI Training:Reminder from Basic EDI Training:

The various tabs in the The various tabs in the Edits Edits MatrixMatrix explain errors. For example: explain errors. For example:

The The ‘Populations Restrictions’‘Populations Restrictions’ tab tab sets out the criteria against which sets out the criteria against which the data is compared; and the data is compared; and

The The ‘Sequencing’‘Sequencing’ tab reveals the tab reveals the MTC/information that must be on MTC/information that must be on file before another MTC can be file before another MTC can be accepted.accepted.

43


The The Element Requirements Table Element Requirements Table (ERT)(ERT) sets out: sets out:

The The data elements requireddata elements required to to be reported on the FROI and be reported on the FROI and SROI formats SROI formats (M, MC, IA, F, FY);(M, MC, IA, F, FY); and and

The The conditionsconditions under which they under which they are expected to be sent are expected to be sent (FROI, (FROI, SROI, & Benefits ‘Conditions’ tabs).SROI, & Benefits ‘Conditions’ tabs).

44


If a data element is not If a data element is not required for a particular FROI required for a particular FROI MTC or SROI MTC, it will be MTC or SROI MTC, it will be denoted as ‘NA’ in the ERT; denoted as ‘NA’ in the ERT;

• If sent, it will If sent, it will notnot be be edited or loaded to edited or loaded to DWC’s database.DWC’s database.

45


File updated Trading File updated Trading Partner paperwork asap Partner paperwork asap when there is a change in when there is a change in your profile-related data, your profile-related data, including address changes, including address changes, additional client additional client insurers, etc., since…insurers, etc., since…

46

… … the FEIN/Zip sent in the the FEIN/Zip sent in the file header for the Sender file header for the Sender ID, and in the transaction ID, and in the transaction detail (claim level) for the detail (claim level) for the Insurer and Claim Admin. Insurer and Claim Admin. must match a FEIN/Zip must match a FEIN/Zip reported on your EDI reported on your EDI Trading Partner Trading Partner paperwork.paperwork.

47

IIf a data element was sent f a data element was sent on a prior filing, and it was on a prior filing, and it was not required, and there not required, and there was an error on the data was an error on the data element, it would not have element, it would not have caused a rejection (e.g. caused a rejection (e.g. Net Weekly Amount on a Net Weekly Amount on a sweep or legacy)…,sweep or legacy)…,

48

… … but if the data but if the data element is required for element is required for the MTC that is currently the MTC that is currently being sent, that same being sent, that same data element will now be data element will now be edited and cause the edited and cause the current MTC to reject. current MTC to reject.

49

Thoroughly research all Thoroughly research all problems and either correct problems and either correct the inaccurate data before re-the inaccurate data before re-sending, or email the EDI team sending, or email the EDI team if you suspect our if you suspect our program/edit may be at fault …program/edit may be at fault …

50

… … After you have After you have thoroughly investigatedthoroughly investigated the error (using DWC the error (using DWC resource documents resource documents covered in the Basic EDI covered in the Basic EDI training) and you still do training) and you still do not understand it, please not understand it, please send an email to send an email to the Claims EDI Team at the Claims EDI Team at [email protected]

51

The EDI Team will The EDI Team will answer all questions answer all questions via an email so that via an email so that both parties have a both parties have a copy of the response copy of the response for future reference... for future reference...

52

……By emailing your By emailing your question, the EDI Team question, the EDI Team has the opportunity to has the opportunity to research the specific research the specific details of the problem details of the problem thoroughly. thoroughly.

Phone calls do not allow Phone calls do not allow adequate time for this adequate time for this research. We appreciate research. We appreciate your understanding. your understanding.

53

Priority attention is given Priority attention is given to emails re: TR’s, so to emails re: TR’s, so TA-FL TA-FL errorserrors that you responded that you responded to may not have been to may not have been closed closed (manual process.)(manual process.)

You should continue to file You should continue to file the appropriate MTC to fix the appropriate MTC to fix the TA-FL, and please be the TA-FL, and please be patient - the Team will patient - the Team will eventually close the TA-eventually close the TA-FL’s.FL’s.

54

Also monitor errors to Also monitor errors to determine if there are determine if there are consistent filing issues that consistent filing issues that could be prevented through could be prevented through training or enhanced system training or enhanced system editing. editing.

See Your See Your Report CardReport Card posted posted in the Data Warehouse for in the Data Warehouse for your your ‘Top 5 Reject Errors’‘Top 5 Reject Errors’ and and ‘Top 5 TA-FL Errors’.‘Top 5 TA-FL Errors’.

55

Note:Note:

There is a There is a new report new report featurefeature available via the available via the Data Warehouse where you Data Warehouse where you can generate can generate a listing of all a listing of all TA-FL errorsTA-FL errors and the and the specific claims that specific claims that received those errors.received those errors.

We will demonstrate this We will demonstrate this feature later in the feature later in the training.training.

56

More detailed More detailed information information regarding the regarding the Claims Claims EDIEDI Data Warehouse Data Warehouse and troubleshooting and troubleshooting errors will errors will also be also be provided provided later in the training.later in the training.

Claims Claims EDI EDI

WarehouWarehousese

57

A separate A separate PowerPoint PowerPoint presentation presentation on the use of on the use of the Data the Data Warehouse is Warehouse is posted on posted on the Claims the Claims EDI web EDI web page.page.

58

Review from Review from Basic EDI Basic EDI TrainingTraining

59

2. Initial 2. Initial PaymentPayment or or EquivalentEquivalent

witwithh

11. Changes11. Changes(Non-(Non-Indemnity)Indemnity)

9. 9. Lump Lump Sum Sum Payment(Payment(s)s)

1. Establish 1. Establish ClaimClaim

4. 4. Suspension Suspension of all of all BenefitsBenefits

3. Changes to 3. Changes to Benefits/AmBenefits/Amntsnts

Benefits

Typical Claim Event Typical Claim Event FlowFlow in FLin FL

10.10.Periodic Periodic ReportsReports

12.12.CancelCancel

8. Claim 8. Claim ClosureClosure

Anytime after First Report and before

Final Report

60

POP QUIZ:POP QUIZ:

Which two Which two formatsformats comprise the IAIABC comprise the IAIABC

standard for reporting standard for reporting workers’ compensation workers’ compensation

data?data?

Review From Basic EDI Review From Basic EDI Training:Training:

61

ANSWER:ANSWER:

FROI and SROIFROI and SROI


62

Another Pop Quiz:Another Pop Quiz:

What What codecode is sent on is sent on the FROI or SROI to the FROI or SROI to

identify the specific identify the specific purpose of each purpose of each transaction being transaction being

transmitted?transmitted?


63

ANSWER:ANSWER:

MTCMTC

Maintenance Maintenance Type CodeType Code


64

The FROI/SROI formats The FROI/SROI formats and specific and specific MTCMTC reported on the FROI reported on the FROI and/or SROI determine and/or SROI determine the electronic form the electronic form equivalent required to equivalent required to be filed with DWC per be filed with DWC per Rule 69L-56Rule 69L-56..


65

Most MTC combinations Most MTC combinations equate to a specific DWC equate to a specific DWC Form that is no longer Form that is no longer required to be filed required to be filed with with DWCDWC. .

Remember, the DWC Form Remember, the DWC Form may still be required to be may still be required to be sent to other parties, sent to other parties, including the EE and including the EE and Employer ...Employer ...


66

… … Refer to the Claims EDI Refer to the Claims EDI Rule 69L-56, F.A.C., for Rule 69L-56, F.A.C., for direction as to which direction as to which parties are to receive a parties are to receive a hardcopy equivalent. hardcopy equivalent.

The Event Table and ‘MTC The Event Table and ‘MTC Filing Instructions’ Filing Instructions’ document also ‘Note’ this document also ‘Note’ this information.information.


67

In addition to the Rule In addition to the Rule 69L-56, which sets out 69L-56, which sets out the various electronic the various electronic form equivalents, the form equivalents, the “MTC to Form “MTC to Form Crosswalk”Crosswalk” provides a one-page provides a one-page

summary of MTC(s) summary of MTC(s) that replaced each DWC that replaced each DWC Form formerly mailed to Form formerly mailed to the Division.the Division.


68

If you have to determine If you have to determine which MTC to send for a which MTC to send for a particular filing particular filing purpose/claim event purpose/claim event because EDI filings are not because EDI filings are not ‘auto-triggered’ in your ‘auto-triggered’ in your system, if it helps you to system, if it helps you to think of how you formerly think of how you formerly reported via paper, refer to reported via paper, refer to the the ‘MTC to Form ‘MTC to Form CrosswalkCrosswalk’’ document for document for guidance.guidance.

69

‘‘MTC to Form MTC to Form Crosswalk’ Crosswalk’ identifies identifies what MTC’s what MTC’s equate to equate to which DWC which DWC forms.forms.

70

MTC to DWC FormMTC to DWC Form

71


72


73


74

Remember not all MTC’s Remember not all MTC’s required to be filed with required to be filed with DWC have a DWC have a corresponding DWC Form corresponding DWC Form (e.g., EP only), so you (e.g., EP only), so you should familiarize should familiarize yourself with the filing yourself with the filing requirements requirements in the rule itself.in the rule itself.


75

FYI:FYI: We plan to workshop We plan to workshop a revised a revised version of the version of the rule in the upcoming year.rule in the upcoming year.

An e-Alert will be sent to An e-Alert will be sent to announce the exact date announce the exact date and location, and we and location, and we would appreciate your would appreciate your participation or written participation or written comments at that time.comments at that time.

76

Proper Filing of Proper Filing of MTC’s Occurring in MTC’s Occurring in the the ‘Life of a Claim‘Life of a Claim’’

77

We will now address We will now address electronic filings/MTC’s that electronic filings/MTC’s that typically occur in the life of a typically occur in the life of a claim, claim, starting with the starting with the Electronic First Report of Electronic First Report of Injury or Illness Injury or Illness (EDI DWC-1 (EDI DWC-1 form equivalents).form equivalents).

Frequent filing issues will be Frequent filing issues will be identified, including identified, including sequencing problems related sequencing problems related to filing downstream to filing downstream SROI MTC’s. SROI MTC’s.

78

Most of today’s Most of today’s training will focus on training will focus on issues related to issues related to SROI MTC’s, SROI MTC’s, since since most errors occur on most errors occur on SROI filings, either in SROI filings, either in combination with the combination with the FROI, or standalone. FROI, or standalone.

79

Caveats will be provided Caveats will be provided for avoiding errors, as for avoiding errors, as well as tips to promote well as tips to promote successful filing.successful filing.

80

Note:Note: In developing EDI In developing EDI edits and requirements, edits and requirements, particularly in relation to particularly in relation to SROI MTC’s, DWC went to SROI MTC’s, DWC went to great lengths to ensure great lengths to ensure that exceptions were that exceptions were created for R3 created for R3 edits/requirements that edits/requirements that did not exist for paper or did not exist for paper or R1 R1 (legacy claims.)(legacy claims.)

81

For purposes of editing, For purposes of editing, ‘‘legacy claims’legacy claims’ are those are those where the ‘Date Claim where the ‘Date Claim Admin. Had Knowledge Admin. Had Knowledge of the Injury’ was prior of the Injury’ was prior to the Trading Partner’s to the Trading Partner’s R3 ‘go live’ date. R3 ‘go live’ date.

Documents

Florida Division of Workers’ Compensation Claims EDI Release 3