Data Edition June The Use of Data at the Division

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1 EDI Newsletter Data Edition June 2017 Inside this issue: May Answer Key 2 Use of Data 3-5 EDI Paperwork 6 Crossword 7 Audit Spotlight 8 DAN Verification 8 Word Search 9 The Use of Data at the Division You may be wondering what we do with all the data we collect electronically. Well before we talk about all that EDI data, let s take a minute to throw back to the days of paper form filings, and picture this. If all the data now submitted electronically (Claims, Proof of Coverage and Medical EDI) were still submitted on paper forms, the annual stack of documents would be nearly 6 times the height of Florida s 22 story Capitol building (see above)! It is truly hard to imagine that we once had to process that much paper. Part of the Division s Mission Statement is to leverage data to deliver exceptional value to our customers and stakeholders. Obviously EDI has had a very positive and significant impact on the Division, enabling us to leverage this data in many beneficial ways. (continued on page 3) NDC Numbers 10 TA-FL Project 10 Contact Information 11 June 2017 Hello! Hope every one had a wonderful May, and has a great June! Happy Father s Day to all the fathers out there! - VL

2 EDI Newsletter Page 2 May Newsletter Puzzle Answers

3 Page 3 The Use of Data at the Division The Bureau of Compliance investigators use the up-to-date EDI Proof of Coverage data as an investigative tool to verify if an employer has a valid workers compensation policy. They also utilize the EDI POC data when they are at job sites conducting investigations. This data also feeds several other web databases used by our customers including our Proof of Coverage database and our Construction Policy Tracking Database. Our Construction Policy Tracking Database is where a general contractor can register on this website to receive an automatic notification about any changes in the workers compensation policy coverage status (e.g. cancellations) for the contractors they ve hired. Access to current coverage information is essential to these functions, and EDI has provided that timely information. Part of the mission of the Division is to ensure the self-execution of the workers compensation system. Our Bureau of Employee Assistance and Ombudsman (EAO) helps to do this by using the Claims EDI First Report of Injury (FROI) data as a trigger to contact injured workers within two days of the Division s receipt of the FROI. They provide the injured worker with benefit entitlement information, answer questions or concerns about the workers compensation system and advise injured workers about services available to them through EAO. The immediate receipt and processing of EDI data every night means our EAO staff can reach injured workers earlier in their claim process. They also use this Claims EDI data to help research and investigate concerns and disputes raised on the Division s hotline about payment of indemnity benefits. The Bureau of Monitoring and Audit ensures that claim administrators meet the requirements of Chapter 440, F.S. Some of the ways they use Claims and Medical EDI data include determining the timeliness of FROI reporting; determining the timeliness and accuracy of initial indemnity benefit payments; determining the timeliness of provider payments and timeliness of medical bill filing with the Division. EDI data are also used during audits to determine if appropriate and timely indemnity and medical benefits have been paid, as well as to validate information filed with the Division and to ensure that required electronic filings have been accepted. The Medical Services Section uses Medical EDI data to resolve reimbursement disputes; to determine what procedure codes will be included in the Healthcare Provider and Hospital Reimbursement Manuals; to provide data to the Three-Member Panel; to determine maximum reimbursement allowances; to conduct research and analyze medical costs for the workers compensation system. The Bureau s Permanent Total (PT) Section also uses Claims EDI data to determine the accuracy of permanent total payments to injured employees; notify claim administrators of inaccuracies; and request correction of any under or overpayments of benefits. They also verify that the correct gross/net weekly amount is used for PT benefit payments; confirm the accuracy of annual cost of living adjustments to permanent total supplemental benefit payments (increased gross/net weekly amount for Benefit Type 021); and identify suspensions of Divisionpaid permanent total supplemental benefits upon notification of settlement or death.

4 The Use of Data at the Division The Division also uses EDI data to respond to inquiries from legislators and policymakers; to meet statutory requirements; and to populate numerous on-line databases and publications for our customers. In addition to the databases mentioned earlier, some additional publications and databases include: Division Results and Accomplishments Report: Claims, POC, and Medical EDI information is used for much of the data provided in the annual Division Results and Accomplishments Report posted to the Division s website. This report includes aggregate claim indemnity and settlement costs per year; distribution of lost-time cases by county; and percentage of lost time claims by Nature of Injury, Cause of Injury and Part of Body (by gender). It also includes medical payments distributed by provider type and amount; total medical paid within 12 months of an injury broken out by provider type; and the total charges and paid amounts for hospital inpatient and outpatient services, health care provider services, and ambulatory surgical center services. Database of Statistical Reports Based on Claims Data: Interested parties can also access the Database of Statistical Reports Based on Claims Data available on the Division s website to generate statistical reports from accident records selected by county, year of injury, nature of injury, or other claim characteristics. The report allows you to query a range of accident years and consists of aggregated data by year of injury for the number of injuries, total benefits and average benefits for each category. Employer Loss Run Database: Interested parties can access a list of lost-time injuries from 1990 to date as reported to the Division regarding particular employers, based on entry of the employer s federal employer identification number (FEIN). The data we collect has also enabled the Division to better help our customers in the industry as well. Some of the examples include: Page 4 Claims EDI Data Warehouse: We have an online data warehouse that every EDI claim administrator/trading partner can access and receive feedback on their EDI filings the morning after they are received. It provides detailed error messages, including identifying potential errors in the compensation rate or under payment of benefits to injured workers. It also provides the trading partner with Report Cards. These report cards provide an accounting of filings accepted and rejected for each trading partner and compared to all other trading partners as a group for the same period of time. Additionally, reports are available that identify missing periodic reports (MTC SA or FN) and rejected filings that have not been resubmitted successfully. These listings can quickly identify problems and help trading partners resolve errors quickly and potentially avoid penalties.

5 Page 5 The Use of Data at the Division Medical EDI Warehouse: We have an online data warehouse that is available for medical submitters to submit bills online. Submitters that submit fewer than 200 bills per month are granted access to submit bills via the warehouse. The website also allows these submitters access to review prior rejected and accepted bills. For the other medical submitters that submit bills via the Secure File Transfer Protocol (SFTP) monthly report cards and detailed reports are provided for submitted bills. Also, twice a month a report is generated with a list of bills that have been rejected and not resubmitted to the Division. Web submitters may access rejected bills that haven t been resubmitted using the Outstanding Rejected Medical Claims Report feature located on the Main Menu. The detailed reports that are generated for batch submitters list any accepted, bypassed, withdrawn, or rejected bills along with their errors. The report cards provide an in depth look at the errors that are being generated by the individual submitter and the common errors for all submitters. The data gathered from the submitted medical bills is monitored by the Centralized Performance System (CPS) to ensure timely filing. Centralized Performance System (CPS): CPS is a web-based application that electronically provides essential insurer performance information and trends. Insurers and claim administrators can electronically view their aggregate First Report of Injury (FROI) or medical timely filing and initial indemnity or medical payment information through the Centralized Performance System. CPS also enables the Division and claim administrators to monitor performance and respond to penalty assessments for untimely filing and untimely payment in real-time. Insurer Regulatory Report: The Bureau of Monitoring and Audit issues this relatively new report to Insurers selected for audit. The report details past performance of the insurer and compares it to the industry s performance. It also contains data from other bureaus, Division news and contact names, phone numbers and addresses. So as you can see, the complete, accurate, and timely reporting of your required EDI data is essential to the Division s ability to carry out its Mission which is, to actively ensure the selfexecution of the workers compensation system through educating and informing all stakeholders of their rights and responsibilities, leveraging data to deliver exceptional value to our customers and stakeholders, and holding parties accountable for meeting their statutory obligations.

6 Page 6 The Importance of Claims EDI Trading Partner Paperwork by Sylvia McKenzie All changes to profile information shall be reported by sending revised Trading Partner Profile documents to DWC at: claims.edi@myfloridacfo.com at least two (2) business days prior to sending transactions containing revised profile-related information. Listed below are a few important helpful hints: The EDI-1 (EDI Trading Partner Profile form) should be sent if you are changing, adding, or removing Sender Information, Business Contacts, or Technical Contacts. The EDI 2 (EDI Trading Partner Insurer/Claim Admin ID List) should be sent if you are adding Insurers or Claim Administrators and will be submitting filings on their behalf. By accurately and timely submitting this form, the Clm Adm FEIN must be valid for Insurer error can be avoided. The EDI-2A (EDI Trading Partner Claim Admin Address List) should be sent when changing, adding, or removing the mailing and/or physical address location combination. With these changes, a FROI 02 (there are less edits to pass) or SROI 02 should be submitted prior to filing any subsequent transactions for all OPEN claims and any claim that has been CLOSED within the last 5 years. The 5 years is a statutory requirement that allows files to be reviewed/audited for a 5 year period. The No match on database for Claim Admin Postal Code and the Clm Adm Alt Zip must = CA Alt Zip on EDI Form 2A errors are common when the EDI-2A is not submitted accurately and timely. The EDI-3 (EDI Transmission Profile Sender s Specification form) should be sent if you are changing or removing vendor information.

7 Page 7 Across 3. Late reason code for wrongful determination of no coverage 4. Denial which serves two purposes; reporting a new claim to the Division while simultaneously denying the claim in its entirety 6. The Federal Employer Identification Number of the Employer where the IW was employed at the time of injury 7. The additional employer who employed the IW independently of the employer associated w/ the injury period 8. Acronym for the first qualifying day in the current period of disability being reported 9. Date a previous denial was revoked 10. Other benefit type for sum of the funeral expenses paid for the claim (include OBT) Down 1. Code identifying that a portion of the NWA is directed to another party on behalf of the IW, but which does not reduce the GWA or affect the NWA 2. Unspecified lump sum payment/settlement benefit type (include BTC) 5. Date associated w/ order as defined by jurisdiction

8 Page 8 Audit Spotlight by Derrick Richardson The Audit Section examines claims-handling practices of insurers, self-insurers, self-insurance funds, and claims-handling entities pursuant to Florida Statute , , , and administrative rules. Examinations and investigations conducted by the Audit Section address patterns and practices of unreasonable delay in claims-handling, timely and accurate payment of benefits to injured workers, timely and accurate filing of required reports, and the inspection and enforcement of compliance with compensation orders of Judges of Compensation Claims. All of the information and data received by the Division are utilized to determine which regulated entities will be audited. Claims handling violations include, but are not limited to: Untimely and/or inaccurate payment of benefits to injured workers Untimely mailing of EAO letters or informational brochures to injured workers Untimely filing and/or payment of medical bills Untimely and/or inaccurate filing of required reports Non-compliance with Orders of Judges of Compensation Claims DAN Verification Project by Justin Hale & Robin Yergin As some of you have noticed we ve begun to send s to trading partners and medical submitters asking about requested Division Assigned Numbers. The purpose of this is to ensure that efforts are being made to obtain the SSN for an injured worker. We ask that you review the spreadsheets, obtain the SSN for the IW in question, and update the claim to reflect that information. For claims reported via Claims EDI a FROI or SROI 02 should be sent. For claims reported via Medical EDI, Bill Submission Reason Code 03 (replacement) should be sent.

9 T I U S X M T D O X F L O F B S I T U S O F I P I B A H P Y L S X B F F R J L K O T E F P Z R J M E S I E A W F I M R A S O L I S N R L A Z Z P R X S Z L G T V E O R I P N S I T S T X B T C A D I S N X O P A J L B F E V H B T T G G H X N I S Z I R T W Q U A A H A Z T R Q P K I A K W H N R D I R B N T L W D O F G L P Q Z I A O F N O I S S I M B U S X T L A I D E N T I S T X E F C X W A P L X B P U C B G G H N M C R V V G Y T U T G P H K J H D H N Word Bank BATCH SUBMISSION FILING SUBMITTER ID FILE RECEIPT BYPASS VALIDATION HOSPITAL DENTIST WITHDRAW

10 Page 10 Reporting NDC Numbers and Tips by Justin Hale In recent months there have been some questions regarding the reporting of National Drug Code numbers. The NDC numbers can only reported on DWC-09 s and DWC-10 s. The NDC numbers can be reported using the format for Revision E. However, for Revision F, the NDC numbers should be reported without dashes or special characters. Additionally, the NDC numbers should be reported as they are billed. If both the primary and secondary fields are being billed, then the same NDC number should not be reported for both fields. Should this occur, please send the bill back to the provider for revision. Also, please remember that if an NDC number primary is billed, it should be reported as such. Please be sure to only report NDC numbers that are billed. The system does allow for an NDC number primary and secondary to be reported on the DWC-09 and 10, but it should only be reported if it was billed. If there are any questions regarding the NDC numbers please reference the MEIG, which is available on the Division s website. If you would like further explanation, please reach out to the Medical EDI team. Additional tips: The NDC Number Secondary should only be present in the NDC Number Primary Field contains a repackaged NDC Number If NDC Number Primary is an OTC Medication, the NDC Secondary field must be blank Responding to TA-FL Error by Justin Hale Additional team members will be assisting with reviewing TA-FL errors in the Warehouse. s containing a list of TA- FLs requiring verification and/ or follow up transactions will be sent. Please assist us in resolving these by responding to the messages left in the Warehouse or by adding comments to the spreadsheets. If you have any questions regarding this project, please reach out to the Claims EDI team at claims.edi@myfloridacfo. com

11 Please contact us! Claims EDI and Medical EDI You can reach the Claims EDI Team by ing us at: You can reach the Medical EDI Team by ing us at: And lastly, if you feel as though you and your team could use additional Training Assistances with the Triage Team, please contact the Triage Claims EDI Contact Tonya Granger at or We would appreciate your feedback! If you have any questions regarding the content of the Newsletter or any issues you may be experiencing please contact us. Or if you have any suggestions for next issues content, please me at