Question: What is an EOBR?
Answer: An EOBR is an Explanation of
Bill Review; it is the notice of payment or notice of
adjustment, disallowance or denial sent by an Insurer,
service company/third party administrator or any entity
acting on behalf of an Insurer to a health care provider
containing code(s) and code descriptor(s), in
conformance with subsection (5) of
69L-7.602, Florida Administrative Code.
Question: Is the term "Explanation
of Bill Review" or acronym "EOBR" required to be on the
form, verbatim or is the title optional?
Answer: The title is optional. The term
"Explanation of Bill Review" is preferred by the
Division, but it is not a requirement. If the document
was titled something differently but still met the
requirements of
69L-7.602, Florida Administrative Code, if it was
the document given to providers to convey the
disposition decision, and the document was presented as
the EOBR, the Division would accept it as such.
Question: May an EOBR contain
unique, in-house EOBR Explanation Codes?
Answer: Yes. Each line item on an EOBR
must contain at least one EOBR Code authorized in
69L-7.602(5)(o), Florida Administrative Code. All
Rule authorized codes must be primary and superior to
any other internal code. After this requirement has been
fulfilled, internal and unique codes may be used and
should be presented in a separate and distinct manner.
Question: Do EOBR codes and
descriptors have to be placed on the EOBR ahead of
Insurer specific payment/denial explanations?
Answer: Yes. Each line item on an EOBR
must contain at least one EOBR Code authorized in
69L-7.602(5)(o), Florida Administrative Code. All
Rule authorized codes must be primary and superior to
any other internal code. After this requirement has been
fulfilled, internal and unique codes may be used and
should be presented in a separate and distinct manner.
Question: Is it permissible to use a
separate and distinct portion of the EOBR to provide
unique codes and descriptions for reductions in addition
to the state specific EOBR codes and descriptions?
Answer: Yes, as long as all other
requirements under
69L-7.602(5)(q), Florida Administrative Code are
met, it is permissible.
Question: Some of our clients
request that we process bills according to the provider
state where services are rendered rather the
jurisdiction state. Do the Requirements in
69L-7.602(5), Florida Administrative Code apply to
this situation?
Answer: Yes. All bills that fall under
Florida Workers' Compensation laws must comply with
69L-7.602(5), Florida Administrative Code.
Question: What if a provider does
not want an EOBR or a Florida specific EOBR?
Answer: An EOBR is still required. All
bills that fall under Florida Workers' Compensation laws
must be responded to in compliance with
69L-7.602(5), Florida Administrative Code.
Question: Is both the Third Party
Administrator’s and the Insurer's information required
on an EOBR?
Answer: The Insurer’s information is
required on all EOBRS, but the Third Party
Administrator's information is not generally required,
but may be listed. Per
69L-7.602(5)(q), Florida Administrative Code, the
specific Insurer’s name, address, and Division issued
Insurer number is required on an EOBR. If the Insurer
has indentified the Third Party Administrator as the
entity designated to receive service on behalf of the
"Insurer and all affected parties" for the purpose of
receiving the petitioner’s service of a copy of a
petition for reimbursement dispute resolution, the Third
Party Administrators' Name and mailing address must
appear on the EOBR.
Question: If an Insurer has a Third
Party Administrator, should the Third Party
Administrator’s mailing address and division issued
number be used in place of the Insurer’s information?
Answer: No. Per
69L-7.602(5)(q), Florida Administrative Code, the
specific Insurer's name, address, and Division issued
Insurer number are required on an EOBR. If the Insurer
has indentified the Third Party Administrator as the
entity designated to receive service on behalf of the
"Insurer and all affected parties" for the purpose of
receiving the petitioner’s service of a copy of a
petition for reimbursement dispute resolution, the Third
Party Administrators' name and mailing address must
appear on the EOBR.
Question: Is an employer's name and
address required on an EOBR?
Answer: No, please refer to
69L-7.602(5)(o), Florida Administrative Code.
Question: Does an EOBR require the
injured employee’s Social Security Number?
Answer: No. Please refer to
69L-7.602(5)(q), Florida Administrative Code.
Question: Does the Insurer's name
and address have to relate to the actual Insurer, or can
it be their TPA?
Answer: The name and address of the
actual Insurer is required to appear on the EOBR. Please
refer to
69L-7.602(5)(q), Florida Administrative Code.
Question: Is the Insurer or Third
Party Administrator responsible for the conveyance of
the EOBR?
Answer: The Insurer is responsible for
communicating its reimbursement decision to the health
care provider. This is done via the EOBR. The Insurer
may delegate this duty to the Third Party Administrator;
however, the Insurer continues to be ultimately
responsible for ensuring that the EOBR is sent to the
provider.
Question: Is an electronic version
of the EOBR acceptable?
Answer: Yes. Whether or not a provider
receives a paper or electronic remittance is up to the
respective parties. However, if the parties agree that
the electronic remittance will serve as the EOBR, that
electronic remittance must include the same elements as
a compliant EOBR, per
69L-7.602(5)(q), Florida Administrative Code. In
addition, the EOBR must be legibly reproduced upon
request.
Question: May an EOBR be used to
respond to reconsideration requests?
Answer: An EOBR must be used if the
reconsideration is in the form of a valid bill. If a
reconsideration arrives in a format other than a valid
bill, an EOBR may be used.
Question: Are there guidelines for
determining importance of EOBR Codes?
Answer: An Insurer may use up to three
(3) EOBR codes and descriptors per billed line item to
explain a reimbursement decision. The EOBR codes should
be listed in order from the Insurer's most important
reason to least important reason. This matter of
importance is determined by the Insurer or its designee.
Please refer to
69L-7.602(5)(o), Florida Administrative Code.
Question: What is the correct value
to put for the Insurer name when a bill is related to a
Self-Insured Entity?
Answer: It would be proper to provide
the name of the Self-Insured Entity along with its
address and Division issued Insurer number. Pursuant to
s. 440.02(38), F.S., a Self-Insured Entity is an
Insurer.
Question: Can the Division provide
examples of valid EOBRs or a blank EOBR form?
Answer: The Division does not have a
standard format for EOBRs. An Insurer can select their
own EOBR format as long as it meets all requirements
found in
69L-7.602(5) , Florida Administrative Code.
Question: Must an EOBR state that it
constitutes notice of disallowance or adjustment of
payment within the meaning of section 440.13(7), F.S.?
Where on the EOBR must this statement be placed?
Answer: Yes, please refer to
69L-7.602(5)(q), Florida Administrative Code. The
statement must appear on the EOBR; however, each insurer
may choose the location of the statement.
Question: If there is a system
limitation that does not allow for population of the
'parenthetical' requirements in the EOBR description,
can the additional information be accounted for in
separate, system-generated messages?
Answer: Yes. System limitations may be
overcome via the use of common abbreviations and
suffixes, as well as by cross-reference within the
parenthetical to carrier unique code or index systems. A
carrier unique code could be placed in the parentheses
and the information could be conveyed elsewhere on the
EOBR.
Question: What if one of the
elements required for an EOBR cannot be possibly met due
to database constrictions such as identifying and
labeling the integral component or inclusive component
in an EOBR description?
Answer: The EOBR would be
non-compliant. However, it is possible that the Division
would work with the Insurer on a case by case basis. If
you have a specific concern about whether or not your
EOBR is compliant, the Bureau of Monitoring and Audit is
happy to review and comment on any entity's EOBR. Please
refer to the contact information at the end of these
FAQs.
Question: Can an Insurer use the
bottom of a check as an EOBR as long as it meets all
requirements?
Answer: Yes. Please keep in mind the
EOBR must be legibly reproduced upon request.
Question: Does an EOBR have to be a
separate document than the reimbursement check?
Answer: No. There is nothing that
prohibits an Insurer from using the check stub or
remittance statement as the EOBR provided it contains
all of the elements of a compliant EOBR. Please keep in
mind the EOBR must be legibly reproduced upon request.
Question: If the Insurer needs to
add a note along with the state EOBR code, can the note
have a code associated with it?
Answer: Yes, as long as the EOBR meets all other
requirements. All rule authorized codes must be primary
and superior to any internal code. After this
requirement has been fulfilled, internal and unique
codes may be used and should be presented in a separate
and distinct manner.
Question: Is it permissible to use a
key or legend to associate a note with a particular line
item if you can't mingle it with the EOBR codes?
Answer: Yes, as long as the EOBR meets
all other requirements.
Question: If a bill was subject to
PPO network reductions and the appropriate EOBR code was
used at the line level, is it appropriate to exclude the
parenthetical stating the PPO network name from that
EOBR code as long as there is a distinct place (box) on
the form that indicates the PPO name, address,
information?
Answer: If the PPO's name was
explicitly indicated as such, it would meet the
requirements.
Question: Is it permissible to print
more than 3 EOBR Codes?
Answer:
69L-7.602(5)(o), Florida Administrative Code, states
that up to three EOBR codes may be utilized for each
line item billed.
If you have further questions, please contact the Division as designated below
Eric Lloyd at
Eric.Lloyd@myfloridacfo.com and
Ryan Gagne at
Ryan.Gagne@myfloridacfo.com
Eric Lloyd at Eric.Lloyd@myfloridacfo.com
Brittany O'Neil at
Brittany.Oneil@myfloridacfo.com and
Barbara Willis at
Barbara.Willis@myfloridacfo.com
