acquired claims: reporting a change in claims administration

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Acquired Claims:Acquired Claims:

Reporting a Change Reporting a Change in in

Claims Claims AdministrationAdministration

Required to be filed with DWC per Required to be filed with DWC per RuleRule 69L-56.304(2), F.A.C. 69L-56.304(2), F.A.C.

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Acquired ClaimsAcquired Claims See Processing Rules: See Processing Rules: Section 4 in the IAIABC EDI Section 4 in the IAIABC EDI

GuideGuide

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Acquired ClaimsAcquired Claims Change in Claims Change in Claims AdministrationAdministration

Claims are Claims are considered to be considered to be “acquired” any time “acquired” any time a new Claim a new Claim Administrator is Administrator is taking them over taking them over from a prior Claim from a prior Claim Administrator. Administrator.

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Any existing claimsAny existing claims (open or closed)(open or closed) that that were transferred to the were transferred to the new Claim Admin. are new Claim Admin. are considered “acquired”.considered “acquired”.


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New reports of injury New reports of injury the acquiring Claim the acquiring Claim Admin. receives Admin. receives afterafter the takeover effective the takeover effective date are date are notnot considered considered acquired claims (would acquired claims (would file 00/IP, etc.).file 00/IP, etc.).


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For reporting to DWC, a For reporting to DWC, a change in acquisition is change in acquisition is required for:required for:

• All OPEN lost time All OPEN lost time claims, and claims, and • Any CLOSED lost time Any CLOSED lost time claims with a DOI claims with a DOI within within FIVEFIVE years prior to the years prior to the date of acquisitiondate of acquisition..


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To report an acquired To report an acquired claim, the new Claim claim, the new Claim Administrator should Administrator should send:send:

• FROI FROI “AQ” (Acquired “AQ” (Acquired Claim)Claim)

(EDI equivalent of(EDI equivalent of DWC- DWC-49).49).


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AQ (Acquired Claim):AQ (Acquired Claim): Minimal data is sent to Minimal data is sent to report that a new Claim report that a new Claim Admin. has acquired the Admin. has acquired the

claim. claim.

Acquired Claims Acquired Claims Change in Claims Change in Claims AdministrationAdministration

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If the If the AQAQ rejects because rejects because the First Report of Injury the First Report of Injury or Illness (paper or EDI) is or Illness (paper or EDI) is not already ‘on file’ with not already ‘on file’ with DWC, the new Claim DWC, the new Claim Admin. must file:Admin. must file:

• FROI FROI AUAU with applicable with applicable SROI. SROI.


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If If AQAQ rejects due to rejects due to match match datadata, email the EDI Team to , email the EDI Team to determine which match data determine which match data element is different & if your element is different & if your data or DWC’s data is correct. data or DWC’s data is correct.

• If DWC’s data is wrong or If DWC’s data is wrong or out of date, we will correct out of date, we will correct our file and reload your our file and reload your filing.filing.


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Subsequent to the Subsequent to the acceptance of the AQ, acceptance of the AQ, when the new Claim when the new Claim Administrator Administrator eventually mails its first eventually mails its first payment of indemnity, payment of indemnity, it should file a SROIit should file a SROI ‘AP ‘AP only’only’ (vs. a standalone (vs. a standalone IP).IP).


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If SROI If SROI APAP does not apply does not apply to the particular claim to the particular claim situation, other situation, other standalone SROI’s may be standalone SROI’s may be sent instead (EP, PY, PD sent instead (EP, PY, PD or SROI 04).or SROI 04).

Acquired ClaimsAcquired Claims Change in Claims Change in Claims

Administration Administration

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Acquired ClaimsAcquired Claims JCNJCN is requiredis required for for ‘standalone’ ‘standalone’ SROI APSROI AP (or (or other SROI equivalent). other SROI equivalent).

• JCN is provided on the JCN is provided on the ACK transaction for the ACK transaction for the previously accepted previously accepted FROI AQ.FROI AQ.

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Acquired ClaimsAcquired Claims

Note:Note: Jurisdiction Claim Jurisdiction Claim Number (JCN) never Number (JCN) never changes. If the former changes. If the former claim administrator claim administrator provided the JCN, it provided the JCN, it would still be valid.would still be valid.

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SROI SROI APAP must only be must only be sent:sent:

• With a FROI AU, or With a FROI AU, or • Subsequent Subsequent to filing to filing a FROI AQ.a FROI AQ.

Change in Claims Change in Claims AdministrationAdministration

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If the new Claim Admin. If the new Claim Admin. acquires a claim acquires a claim and and initiates payment,initiates payment, the the new Claim Admin. must new Claim Admin. must file:file:

• FROI FROI AUAU ++ SROI SROI APAP (Acquired Payment)(Acquired Payment)


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If If SROI SROI APAP does not does not apply to the filing apply to the filing situation, other SROI situation, other SROI MTC’s may be sent MTC’s may be sent instead…instead…


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• FROI AU FROI AU + + SROI SROI EPEP • FROIFROI AU AU + + SROI SROI CDCD • FROI AU FROI AU + + SROI SROI VEVE • FROI AU FROI AU + + SROI SROI PYPY • FROI AU FROI AU + + SROI SROI PDPD • FROI AU FROI AU + + SROI SROI 0404


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Jurisdiction Claim Number Jurisdiction Claim Number (JCN) is (JCN) is not requirednot required for for

FROI “AQ”, or FROI “AQ”, or FROI “AU” + FROI “AU” +

applicable SROI applicable SROI


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Acquired ClaimsAcquired Claims All prior indemnity paid All prior indemnity paid by the former Claim by the former Claim Administrator(s) must be Administrator(s) must be rolled up and reported on rolled up and reported on the SROI under:the SROI under:• Other Benefit Type 430Other Benefit Type 430 (Total Unallocated Prior (Total Unallocated Prior Indemnity Benefits). Indemnity Benefits).

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Acquired ClaimsAcquired Claims Note:Note: Presence of OBT 430 Presence of OBT 430 alone will not prevent the edit, alone will not prevent the edit, ‘Ben Type Amount Paid < Prev. ‘Ben Type Amount Paid < Prev. Reported’ from running. Reported’ from running.

• Total of all Benefit Type Total of all Benefit Type Amount Paid (for all BTC’s) Amount Paid (for all BTC’s) plus plus OBT 430 must be at OBT 430 must be at least equal to all BTC least equal to all BTC amounts previously amounts previously reported.reported.

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Acquired ClaimsAcquired Claims If the only prior indemnity If the only prior indemnity reported by the former reported by the former Claim Admin. was Claim Admin. was 2xx,2xx, the the current Claim Admin. should current Claim Admin. should report the actual $ under report the actual $ under OBT 430 if BTC OBT 430 if BTC other than other than 240240 was paid. was paid.

• If only BTC 240 was paid, If only BTC 240 was paid, FL’s program will accept FL’s program will accept $0 in the OBT 430 field, $0 in the OBT 430 field, however …however …

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Acquired ClaimsAcquired Claims… … OBT 430 is currently OBT 430 is currently defined as the “sum of prior defined as the “sum of prior indemnity benefits indemnity benefits ‘‘paid’paid’ to to date by the previous claim date by the previous claim administrator(sadministrator(s)”, and BTC )”, and BTC 240 Employer Paid benefits 240 Employer Paid benefits are not paid by the Claim are not paid by the Claim Administrator.Administrator.

As a result of this conflict … As a result of this conflict …

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Acquired ClaimsAcquired Claims… … FL submitted an IRR FL submitted an IRR with the IAIABC with the IAIABC requesting a requesting a standardized approach standardized approach to this filing dilemma …to this filing dilemma …

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Proposed solutions include:Proposed solutions include: Appropriation of a new Appropriation of a new OBT Code, or OBT Code, or Allow OBT 430 to be Allow OBT 430 to be reported w/ $0,reported w/ $0, or or

Allow BTC 240 to continue Allow BTC 240 to continue to be reported in the to be reported in the BenefitsBenefits segment segment (vs. moved (vs. moved to an OBT segment.) to an OBT segment.)


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FL does FL does notnot require require OBT OBT Code 440 (Total Code 440 (Total Unallocated Prior Medical)Unallocated Prior Medical) to report the amount the to report the amount the prior Claim Admin. paid in prior Claim Admin. paid in medical because those medical because those costs are collected via costs are collected via DWC’s Medical EDI DWC’s Medical EDI program.program.


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The The newnew Claim Admin. must Claim Admin. must also report certain medical also report certain medical costs costs paidpaid since the since the acquisition of the claim. acquisition of the claim.

• Report under Report under “Other “Other Benefit Type Codes”Benefit Type Codes”,, e.g., e.g., OBT Code 370 (Total Other OBT Code 370 (Total Other Medical), etc. Medical), etc.


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If DWC-1 is not already If DWC-1 is not already on file, AU + SROI will:on file, AU + SROI will:

• Establish initial claim Establish initial claim record in DWC’s record in DWC’s database, and database, and • Be evaluated for timely Be evaluated for timely filing of the initial report filing of the initial report of injury to DWC.of injury to DWC.


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POP QUIZ:POP QUIZ:

If If nono indemnity was indemnity was paid by the paid by the former Claim Admin. but former Claim Admin. but the new Claim Admin. is the new Claim Admin. is denying the claim in its denying the claim in its entirety and there is no entirety and there is no DWC-1 on file with DWC, DWC-1 on file with DWC, what should be sent? what should be sent?

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ANSWER:ANSWER:

FROI FROI AU AU + SROI + SROI 0404

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FROIFROI AUAU + SROI+ SROI 0404 should be should be sent rather than a FROI 04 sent rather than a FROI 04 because there is no way to because there is no way to convey an Acquired Denial convey an Acquired Denial with a FROI 04. with a FROI 04.

•If the denial is rescinded, an If the denial is rescinded, an AP would reject if there was AP would reject if there was no prior AQ or AU on file.no prior AQ or AU on file.


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If the acquiring Claim If the acquiring Claim Admin. sends an AQ that Admin. sends an AQ that rejects because there is no rejects because there is no DWC-1 on file, and if no DWC-1 on file, and if no SROI is applicable to the SROI is applicable to the present filing situation present filing situation (e.g., you are not making (e.g., you are not making payment or denying) … payment or denying) …


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… … at the present time, the at the present time, the acquiring Claim Admin. will acquiring Claim Admin. will need to fax a paper DWC-1 need to fax a paper DWC-1 (copy of original) to EDI (copy of original) to EDI Team at (850) 488-3453. Team at (850) 488-3453.

• If you have ‘a lot’ that will If you have ‘a lot’ that will fall into this situation, fall into this situation, contact the Claims EDI contact the Claims EDI Team before mailing ‘lots’ Team before mailing ‘lots’ of paper DWC-1’s.of paper DWC-1’s.


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Note:Note: Even though the Even though the former TPA should have former TPA should have filed the First Report of filed the First Report of Injury or Illness (paper or Injury or Illness (paper or EDI) with DWC, the new EDI) with DWC, the new TPA is still required to file TPA is still required to file the FROI, because the FROI, because the the Insurer is ultimately Insurer is ultimately responsibleresponsible . .


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Acquired ClaimsAcquired Claims Corrections of an Corrections of an incorrect Insurer FEINincorrect Insurer FEIN (reported on a prior paper (reported on a prior paper or EDI filing) or EDI filing) to another to another Insurer FEIN within the Insurer FEIN within the same insurer same insurer group/relationshipgroup/relationship, are , are notnot considered changes in considered changes in claims administration and claims administration and may be changed via MTC may be changed via MTC 0202..

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Acquired ClaimsAcquired Claims If 02 is sent to report a If 02 is sent to report a change in FEIN change in FEIN and MTC 02 and MTC 02 is included in the Ben is included in the Ben segmentsegment,,

• All previously reported All previously reported

indemnity will be required indemnity will be required

on the 02. on the 02.

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Recap:Recap: If AQ or AU/SROI is If AQ or AU/SROI is

sent to report an actual sent to report an actual

change in administration, change in administration,

all all indemnityindemnity paid by the paid by the

former Claim Admin. must former Claim Admin. must

be rolled up into OBT 430be rolled up into OBT 430

before sending the next before sending the next

SROI event … SROI event …

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Acquired Claims Acquired Claims … because … because by definition, “Benefit by definition, “Benefit Period Start Date” is Period Start Date” is reset and should only reset and should only represent indemnity paid represent indemnity paid by the by the newnew Claim Admin. Claim Admin. Therefore, it is not Therefore, it is not appropriate to include appropriate to include the prior claim admin the prior claim admin payments in the Benefits payments in the Benefits segment.segment.

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OBT Code 430 (Total OBT Code 430 (Total Unallocated Prior Indemnity)Unallocated Prior Indemnity) must not be reported unless:must not be reported unless:

•MTC AQ, AU or AP is on file or being MTC AQ, AU or AP is on file or being filed, OR filed, OR

•Date Claim Admin. Had Knowledge Date Claim Admin. Had Knowledge of Injury is prior to the Claim of Injury is prior to the Claim Admin.’s R3 Production Admin.’s R3 Production Implementation Date. Implementation Date.


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Recap:Recap: If there is no If there is no actual change, but actual change, but rather a rather a correctioncorrection in in claims administration, claims administration, MTC 02MTC 02 should be should be sent.sent.

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Benefits Benefits Segment Segment

Definitions Definitions

Acquired Claims Acquired Claims

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““Gross Weekly Amount”Gross Weekly Amount” andand “Net Weekly “Net Weekly

Amount”Amount”

BENEFITS BENEFITS Segment - Segment - Acquired Acquired ClaimsClaims

The Gross and Net Weekly The Gross and Net Weekly Amounts apply to the Amounts apply to the Acquiring Claim Acquiring Claim Administrator’s payment, Administrator’s payment, rather than the previous rather than the previous Claim Administrator’s Claim Administrator’s payments.payments.

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““Gross Weekly Amount Gross Weekly Amount Effective Date” “Net Weekly Effective Date” “Net Weekly

Amount Effective Date”Amount Effective Date”

The Gross and Net Weekly The Gross and Net Weekly Amount Effective Dates are Amount Effective Dates are the date the date the acquiring claim the acquiring claim administratoradministrator assumed assumed responsibility for handling responsibility for handling the claim.the claim.


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““Benefit Period Start Date”Benefit Period Start Date”For MTC “AP” and all subsequent For MTC “AP” and all subsequent MTC’s filed on acquired claims, the MTC’s filed on acquired claims, the Benefit Period Start Date is the Benefit Period Start Date is the first first date of the uninterrupted period of date of the uninterrupted period of benefit payments by the acquiring benefit payments by the acquiring Claim Administrator Claim Administrator corresponding to a specific corresponding to a specific Benefit Type Code. Benefit Type Code.


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“ “Benefit Period Through Benefit Period Through Date”Date”

For all MTC’s that are For all MTC’s that are initiating or reinstating a initiating or reinstating a Benefit Type Code Benefit Type Code (AB, (AB, APAP, IP, RB, EP, ER, CB): , IP, RB, EP, ER, CB): The Benefit Period Through The Benefit Period Through Date is Date is the latest date of the the latest date of the uninterrupted period of uninterrupted period of benefit paymentsbenefit paymentsthat corresponds to the that corresponds to the Benefit Type Code.Benefit Type Code.


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“ “Benefit Type Claim Benefit Type Claim Weeks/Days” Weeks/Days”

For acquired claims, Benefit Type For acquired claims, Benefit Type Claim Weeks/Days will be the Claim Weeks/Days will be the cumulative number of whole cumulative number of whole weeks and residual number of weeks and residual number of days paid for a Benefit Type Code days paid for a Benefit Type Code by the acquiring claim by the acquiring claim administrator.administrator.


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““Benefit Type Amount Benefit Type Amount

Paid”Paid”

For acquired claims, the For acquired claims, the Benefit Type Amount Paid Benefit Type Amount Paid will be the cumulative will be the cumulative paid to date amount by paid to date amount by the acquiring claim the acquiring claim administrator.administrator.


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Questions?Questions?

acquired claims: reporting a change in claims administration

Documents

claims jcn

claims administrationaq

claims administrationclaims

froi au sroi ap

new claim administrator

froi au applicable sroi

open lost time claims

closed lost time claims