(5) Insurer Responsibilities.
(a) An insurer is responsible for meeting its obligations under this
rule regardless of any business arrangements with any service
company/TPA, submitter or any entity acting on behalf of an insurer
under which claims are paid, adjusted and paid, disallowed, denied,
or otherwise processed or submitted to the Division.
(b) At the time of authorization for medical service(s) or at the
time a reimbursement request is received, an insurer shall notify
each health care provider, in writing, of additional form completion
requirements or supporting documentation that are necessary for
reimbursement determinations.
(c) At the time of authorization for medical service(s), an insurer
shall inform in-state and out-of-state health care providers of the
specific reporting, billing and submission requirements of this rule
and provide the specific address for submitting a reimbursement
request.
(d) Insurers, service company/TPAs or entities acting on behalf of
insurers and health care providers shall utilize only the Form
DFS-F5-DWC-25 for physician reporting of an injured employee’s
medical treatment/status. Any other reporting forms may not be used
in lieu of or supplemental to the Form DFS-F5-DWC-25.
(e) Required data elements on each Form DFS-F5-DWC-9, DFS-F5-DWC-10,
DFS-F5-DWC-11, and DFS-F5-DWC-90, for both medical only and
lost-time cases, shall be filed with the Division within 45-calendar
days of when the medical bill is paid, adjusted, disallowed or
denied by the insurer, service company/TPA or any entity acting on
behalf of the insurer. The 45-calendar day filing requirement
includes initial submission and correction and re-submission of all
errors identified in the “Medical Claim Processing Report”, as
defined in the date-applicable Florida Medical EDI Implementation
Guide (MEIG).
(f) An insurer shall be responsible for accurately completing
required data filed with the Division, pursuant to the
date-applicable Florida Medical EDI Implementation Guide (MEIG) and
subparagraphs (4)(c)2.-5. of this rule.
(g) When an injured employee does not have a Social Security Number
or division-assigned number, the insurer must contact the Division
via information provided on the following website:
http://www.fldfs.com/WC/organization/odqc.html (under Records
Management) to obtain a division-assigned number prior to submitting
the medical report to the Division.
(h) An insurer, service company/TPA or any entity acting on behalf
of an insurer must report to the Division the procedure code(s),
number of line-items billed, diagnosis code(s), modifier code(s) and
amount(s) charged, as billed by the health care provider when
reporting these data to the Division. However, the insurer, service
company/TPA or any entity acting on behalf of an insurer may correct
the procedure code(s) or modifier code(s) to effect payment and
shall report both the provider billed code(s) and insurer adjusted
code(s) pursuant to the date-appropriate MEIG. The insurer, service
company/TPA or any entity acting on behalf of an insurer shall
utilize the EOBR code “80” to notify the health care provider
concerning any such billing errors and shall transmit EOBR code
“80”, in instances when the carrier corrects the provider coding,
when reporting to the Division.
(i) An insurer, service company/TPA or any entity acting on behalf
of the insurer shall manually or electronically date stamp
accurately completed Forms DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer
pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the
electronic form equivalent on the “date insurer received” as defined
in paragraph (1)(m) of this rule.
(j)1. When a medical bill is submitted for reimbursement by a health
care provider, the insurer, service company/TPA or entity acting on
behalf of the insurer must review the medical bill to determine if
any of the criteria in subparagraph (5)(j)5. of this rule are
present. If a medical bill meets any of the criteria listed in
subparagraph (5)(j)5. of this rule, the insurer, service company/TPA
or entity acting on behalf of the insurer must either:
a. Secure and/or correct the information on the medical bill and
proceed to make a reimbursement decision to pay, adjust, disallow or
deny billed charges within 45-calendar days from the “date insurer
received”; or
b. Return the medical bill to the provider with a written statement
identifying the criteria under which the medical bill is being
returned within twenty-one (21) days of the “Date Insurer Received”.
The written statement sent to the provider with the returned medical
bill shall bear the following statement CAPITALIZED and in
BOLD print: “A HEALTH CARE PROVIDER MAY NOT BILL
THE INJURED EMPLOYEE FOR SERVICES RENDERED FOR A COMPENSABLE
WORK-RELATED INJURY”.
2. If the insurer returns a medical bill to the provider pursuant to
subparagraph (5)(j)5. of this rule, the written statement must
include all criteria upon which the return of the medical bill are
based.
3. If the criterion upon which the return of the medical bill is
based includes any of the criteria in sub-subparagraphs (5)(j)5.d.-f
. of this rule, the written statement must identify the information
that is illegible, incorrect, or omitted.
4. An insurer may return a medical bill to a provider without
issuance of an EOBR only on the basis of the criteria set forth in
subparagraph (5)(j)5. of this rule.
5. The criteria upon which a medical bill is to be reviewed by the
insurer, service company/TPA or entity acting on behalf of the
insurer for return to the provider pursuant to this sub-paragraph of
paragraph (5)(j) of this rule are:
a. Services are billed on an incorrect medical billing form; or
b. The medical bill has been submitted to the incorrect insurer; or
c. The medical bill has been submitted to the incorrect service
company/TPA or entity acting on behalf of the insurer; or
d. Claimant identification information required by this rule is
illegible on the medical bill; or
e. Claimant identification information required by this rule is
incorrect on the medical bill; or
f. Billing information required by this rule is omitted on the
medical bill.
6. An insurer, service company/TPA or entity acting on behalf of the
insurer shall establish and maintain a process by which medical
bills that have been returned and written statements identifying the
reason for return are compiled. The compiled information must be
sufficiently detailed to allow verification and review by the
Division.
(k) An insurer, service company/TPA or any entity acting on behalf
of the insurer shall pay, adjust, disallow or deny billed charges
within 45-calendar days from the date insurer received, pursuant to
Section 440.20(2)(b), F.S.
(l) In the medical bill claims-handling process, the receipt of
medical bills may be based upon receipt by the insurer or there may
be an “entity” acting on behalf of an insurer for purposes of
receipt of medical bills. Likewise, the payment of medical bills may
be based upon payment by the insurer or there may be an “entity”
acting on behalf of an insurer for purposes of payment of medical
bills. Therefore, to properly reflect receipt date and payment date
of medical bills, the medical bill reporting process must
accommodate various receipt and payment options.
1. The receipt and payment option utilized by an insurer and
reported to the Division must meet one of the following:
a. Both receipt and payment of medical bills are handled by the
insurer. This option may be utilized only when the “date insurer
received” is the date the insurer gained possession of the health
care provider’s medical bill, and the “date insurer paid” is the
date the health care provider’s payment is mailed, transferred or
electronically transmitted by the insurer. This option may not be
utilized when a health care provider is required by the insurer to
submit medical billings to any “entity” other than the insurer.
b. Both receipt and payment of medical bills are handled by any
“entity” acting on behalf of the insurer. This option may be
utilized only when the “date insurer received” is the date the
“entity” acting on behalf of the insurer gained possession of the
health care provider’s medical bill, and the “date insurer paid” is
the date the health care provider’s payment is mailed, transferred
or electronically transmitted by the “entity” acting on behalf of
the insurer. This option may not be utilized when a health care
provider is required by the insurer to submit medical billings
directly to the insurer.
c. Receipt of medical bills is handled by the insurer and payment of
medical bills is handled by the “entity” acting on behalf of the
insurer. This option may be utilized only when the “date insurer
received” is the date the insurer gained possession of the health
care provider’s medical bill, and the “date insurer paid” is the
date the health care provider’s payment is mailed, transferred or
electronically transmitted by the “entity” acting on behalf of the
insurer. This option may not be utilized when a health care provider
is required by the insurer to submit medical billings to any
“entity” other than the insurer.
d. Receipt of medical bills is handled by any “entity” acting on
behalf of the insurer and payment of medical bills is handled by the
insurer. This option may be utilized only when the “date insurer
received” is the date the “entity” acting on behalf of the insurer
gained possession of the health care provider’s medical bill, and
the “date insurer paid” is the date the health care provider’s
payment is mailed, transferred or electronically transmitted by the
insurer. This option may not be utilized when a health care provider
is required by the insurer to submit medical billings directly to
the insurer.
2. The insurer must:
a. Document the option(s) selected in subparagraph (5)(l)1. of this
rule,
b. Document the specific effective date for each option selected,
c. Document the specific role of each “entity” acting on the
insurers behalf in the option selected,
d. Make this written documentation available to the Division for
audit purposes pursuant to Section 440.525, F.S.,
e. Maintain written documentation from the “entity” acknowledging
its responsibilities concerning “date insurer received” and “date
insurer paid” for each option when the insurer selects options b.,
c., or d. from subparagraph (5)(l)1. of this rule, and
f. Maintain written documentation identifying the applicability of
the options selected in sufficient detail to allow verification of
the coding of each medical bill under subparagraph (5)(l)4. of this
rule.
3. An insurer and entity may select multiple options for medical
bill claims handling between the insurer and the entity based on
business practices or whether medical bills are submitted to the
insurer electronically or on paper.
4. The option in subparagraph (5)(l)1. of this rule selected by the
insurer must be identified on each medical report electronic
submission to the Division and must utilize the following coding
methodology:
a. If the “date insurer received” is the date the insurer gains
possession of the health care provider’s medical bill and the “date
insurer paid” is the date the health care provider’s payment is
mailed, transferred or electronically transmitted by the insurer,
then Payment Code “x” 1 must be transmitted on each individual
form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as
denoted in Appendix D of the date-appropriate Florida Medical
Implementation EDI Guide (MEIG).) When submitting Payment Code “x” 1
to the Division, the insurer is declaring that no “entity” as
defined in paragraph (1)(u) of this rule is involved in the medical
bill claims-handling processes related to “date insurer received” or
“date insurer paid”.
b. If the “date insurer received” is the date the “entity” acting on
behalf of the insurer gains possession of the health care provider’s
medical bill and the “date insurer paid” is the date the health care
provider’s payment is mailed, transferred or electronically
transmitted by the “entity” acting on behalf of the insurer, then
Payment Code “x” 2 must be transmitted on each individual form-type
electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in
Appendix D of the date-appropriate Florida Medical Implementation
EDI Guide (MEIG).) When submitting Payment Code “x” 2 to the
Division, the insurer is declaring that the specified “entity” as
defined in paragraph (1)(u) of this rule is acting on behalf of the
insurer for purposes of the medical bill claims-handling processes
related to “date insurer received” and “date insurer paid”.
c. If the “date insurer received” is the date the insurer gains
possession of the health care provider’s medical bill and “date
insurer paid” is the date the health care provider’s payment is
mailed, transferred or electronically transmitted by the “entity”
acting on behalf of the insurer, then Payment Code “x” 3 must be
transmitted on each individual form-type electronic submission. (“x”
must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the
date-appropriate Florida Medical Implementation EDI Guide (MEIG).)
When submitting Payment Code “x” 3 to the Division, the insurer is
declaring that no “entity” as defined in paragraph (1)(u) of this
rule is involved in the medical bill claims-handling process related
to “date insurer received”.
d. If the “date insurer received” is the date the “entity” acting on
behalf of the insurer gains possession of the health care provider’s
medical bill and the “date insurer paid” is the date the health care
provider’s payment is mailed, transferred or electronically
transmitted by the insurer, then Payment Code “x” 4 must be
transmitted on each individual form-type electronic submission. (“x”
must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the
date-appropriate Florida Medical Implementation EDI Guide (MEIG).)
When submitting Payment Code “x” 4 to the Division, the insurer is
declaring that no “entity” as defined in paragraph (1)(u) is
involved in the medical bill claims-handling processes related to
“date insurer paid”.
(m) An insurer, service company/TPA or any entity acting on behalf
of the insurer, when reporting paid medical claims data to the
Division, shall report the dollar amount paid by the insurer or
reimbursed to the employee, the employer or other insurer for
healthcare service(s) or supply(ies). When reporting disallowed or
denied charges, the dollar amount paid shall be reported as $0.00.
(n) An insurer, service company/TPA or any entity acting on behalf
of the insurer is not required to report electronically as medical
payment data to the Division, those payments made for failed
appointments for scheduled independent medical examinations, for
federal facilities billing on their usual form or for health care
providers in subparagraph (4)(b)13. who bill on their invoice or
letterhead.
(o) A submitter, filing electronically, shall submit to the Division
the Explanation of Bill Review (EOBR) code(s), relating to the
adjudication of each line item billed and:
1. Maintain the EOBR in a format that can be legibly reproduced, and
2. Use the EOBR codes and code descriptors as follows up through the
date for reporting production data with the Medical Data System in
the Claim Record Layout-Revision “D” as required in subparagraph
(6)(f) of this rule:
a. 01 Services not authorized, as required.
b. 02 Services denied as not related to the compensable work injury.
c. 03 Services related to a denied work injury: Form DFS-F2-DWC-12
on file with the Division.
d. 04 Services billed are listed as not covered or non-covered
(“NC”) in the applicable reimbursement manual.
e. 05 Documentation does not support the level, intensity,
frequency, duration or provision of service(s) billed. (Insurer must
specify to the health care provider.)
f. 06 Location of service(s) is not consistent with the level of
service(s) billed.
g. 07 Reimbursement equals the amount billed.
h. 08 Reimbursement is based on the applicable reimbursement fee
schedule.
i. 09 Reimbursement is based on any contract.
j. 10 Reimbursement is based on charges exceeding the stop-loss
point.
k. 11 Reimbursement is based on insurer re-coding. (Insurer must
specify to the health care provider.)
l. 12 Charge(s) are included in the per diem reimbursement.
m. 13 Reimbursement is included in the allowance of another service.
(Insurer must specify procedure to the health care provider.)
n. 14 Itemized statement not submitted with billing form.
o. 15 Invalid code. (Use only when other valid codes are present.)
p. 16 Documentation does not support that services rendered were
medically necessary.
q. 17 Required supplemental documentation not filed with the bill.
(Insurer must specify required documentation to the health care
provider.)
r. 18 Duplicate Billing: Service previously paid, adjusted and paid,
disallowed or denied on prior claim form or multiple billing of
service(s) billed on same date of service.
s. 19 Required Form DFS-F5-DWC-25 not submitted within three
business days of the first treatment pursuant to Section
440.13(4)(a), F.S.
t. 20 Other: Unique EOBR code descriptor. Use of EOBR code “20” is
restricted to circumstances when an above-listed EOBR code does not
explain the reason for payment, adjustment and payment, disallowance
or denial of payment. When using EOBR code “20”, an insurer must
reflect code “20” and include the specific explanation of the code
on the EOBR sent to the health care provider. The insurer, service
company/TPA or any entity acting on behalf of the insurer must
maintain a standardized EOBR code descriptor list.
3. When reporting production data with the Medical Data System in
the Claim Record Layout-Revision “D” as required in subparagraph
(6)(f) of this rule, the insurer shall comply with the following
instructions pertaining to EOBRs: In completing an Explanation of
Bill Review (EOBR) an insurer shall, for each line item billed,
select the EOBR code(s) from the list below which identifies(y) the
reason(s) for the insurer’s reimbursement decision for each line
item. The insurer may utilize up to three EOBR codes for each line
item billed. When utilizing more than one EOBR, the insurer shall
list the EOBR codes that describe the basis for its reimbursement
decision in descending order of importance. An insurer, service
company/TPA or any entity acting on behalf of the insurer shall
submit to the Division the Explanation of Bill Review (EOBR) code,
relating to the adjudication of each line item billed, in descending
order of importance.
The EOBR code list is as follows:
10 – Payment denied: compensability: injury or illness for which
service was rendered is not compensable.
21 – Payment disallowed: medical necessity: medical records reflect
no physician’s order was given for service rendered or supply
provided.
22 – Payment disallowed: medical necessity: medical records reflect
no physician’s prescription was given for service rendered or supply
provided.
23 – Payment disallowed: medical necessity: diagnosis does not
support the service rendered.
24 – Payment disallowed: medical necessity: service rendered was not
therapeutically appropriate.
25 – Payment disallowed: medical necessity: service rendered was
experimental, investigative or research in nature.
26 – Payment disallowed: service rendered by healthcare practitioner
outside scope of practitioner’s licensure.
30 – Payment disallowed: lack of authorization: no authorization
given for service rendered.
40 – Payment disallowed: insufficient documentation: documentation
does not substantiate the service billed was rendered.41 – Payment
disallowed: insufficient documentation: level of evaluation and
management service not supported by documentation.
42 – Payment disallowed: insufficient documentation: intensity of
physical medicine and rehabilitation service not supported by
documentation.
43 – Payment disallowed: insufficient documentation: frequency of
service not supported by documentation.
44 – Payment disallowed: insufficient documentation: duration of
service not supported by documentation.
45 – Payment disallowed: insufficient documentation: fraud statement
not provided pursuant to Section 440.105(7), F.S.
46 – Payment disallowed: insufficient documentation: required
itemized statement not submitted with the medical bill.
47 – Payment disallowed: insufficient documentation: invoice not
submitted for implant.
48 – Payment disallowed: insufficient documentation: invoice not
submitted for supplies.
49 – Payment disallowed: insufficient documentation: invoice not
submitted for medication.
50 – Payment disallowed: insufficient documentation: requested
documentation not submitted with the medical bill.
51 – Payment disallowed: insufficient documentation: required
DFS-F5-DWC-25 not submitted.
52 – Payment disallowed: insufficient documentation: supply(ies)
incidental to the procedure.
53 – Payment disallowed: insufficient documentation: required
operative report not submitted with the medical bill.
54 – Payment disallowed: insufficient documentation: required
narrative report not submitted with the medical bill.
60 – Payment disallowed: billing error: service previously billed
and processed on prior medical bill.
61 – Payment disallowed: billing error: same service billed multiple
times on same date of service.
62 – Payment disallowed: billing error: incorrect procedure,
modifier or supply code.
63 – Payment disallowed: billing error: service billed is integral
component of another procedure code.
64 – Payment disallowed: billing error: service “not covered” under
applicable workers’ compensation reimbursement manual.
65 – Payment disallowed: billing error: multiple providers billed on
the same form.
71 – Payment adjusted: insufficient documentation: level of
evaluation and management service not supported by documentation.
72 – Payment adjusted: insufficient documentation: intensity of
physical medicine and rehabilitation service not supported by
documentation.
73 – Payment adjusted: insufficient documentation: frequency of
service not supported by documentation.
74 – Payment adjusted: insufficient documentation: duration of
service not supported by documentation.
75 – Payment adjusted: insufficient documentation: requested
documentation not submitted with the medical bill.
80 – Payment adjusted: billing error: correction of procedure,
modifier or supply code.
81 – Payment adjusted: billing error: payment modified pursuant to a
charge audit.
82 – Payment adjusted: payment modified pursuant to carrier charge
analysis.
83 – Payment adjusted: medical benefits paid apportioning out the
percentage of the need for such care attributable to preexisting
condition (Section 440.15(5)(b), F.S.).
84 – Payment adjusted: co-payment applied pursuant to Section
440.13(14)(c), F.S.
90 – Paid: no modification to the information provided on the
medical bill: payment made pursuant to Florida Workers’ Compensation
Health Care Provider Reimbursement Manual.
91 – Paid: no modification to the information provided on the
medical bill: payment made pursuant to Florida Workers’ Compensation
Reimbursement Manual for Ambulatory Surgical Centers.
92 – Paid: no modification to the information provided on the
medical bill: payment made pursuant to Florida Workers’ Compensation
Reimbursement Manual for Hospitals.
93 – Paid: no modification to the information provided on the
medical bill: payment made pursuant to contractual arrangement.
94 – Paid: Out-of-State Provider: payment made pursuant to the
Out-of-State Provider section of the applicable Florida
reimbursement manual.
95 – Paid: Reimbursement Dispute Resolution: payment made pursuant
to receipt of a Determination or Final Order on a Petition for
Resolution of Reimbursement Dispute, pursuant to Section 440.13(7),
F.S.
(p) An insurer, service company/TPA, submitter or any entity acting
on behalf of the insurer shall make available to the Division and to
the Agency, upon request and without charge, a legibly reproduced
copy of the electronic form equivalents or Forms DFS-F5-DWC-9,
DFS-F5-DWC-10 (or insurer pre-approved alternate form),
DFS-F5-DWC-11, DFS-F5-DWC-25, DFS-F5-DWC-90, supplemental
documentation, proof of payment, EOBR and the insurer written
documentation required in subparagraphs (5)(j)6. and (5)(l)2. of
this rule.
(q) An insurer, service company/TPA or any entity acting on behalf
of the insurer to pay, adjust, disallow or deny a filed bill shall
submit to the health care provider an Explanation of Bill Review,
utilizing the EOBR codes and code descriptors, as set forth in
paragraph (o) of this section, and shall include the insurer name
and specific insurer contact information. An insurer, service
company/TPA or any entity acting on behalf of the insurer shall
notify the health care provider of notice of payment or notice of
adjustment, disallowance or denial only through an EOBR. An EOBR
shall specifically state that the EOBR constitutes notice of
disallowance or adjustment of payment within the meaning of Section
440.13(7), F.S. An EOBR shall specifically identify the name and
mailing address of the entity the carrier designates to receive
service on behalf of the “carrier and all affected parties” for the
purpose of receiving the petitioner’s service of a copy of a
petition for reimbursement dispute resolution by certified mail,
pursuant to Section 440.13(7)(a), F.S.
(r) Copies of hospital medical records shall be subject to charges
allowed pursuant to Section 395.3025, F.S. and Section 440.13, F.S.
(s) When an insurer, service company/TPA or any entity acting on
behalf of the insurer renders reimbursement as pre-payment for
medical services, goods or supplies, reimbursement of employee
payment or payment for pharmacy first-fill services, the required
data elements, optionally including the appropriate
Pre-Payment/Employee Payment/First Fill Indicator as described in
the MEIG, shall be submitted to the Division within 45 calendar days
of the insurer, service company/TPA or any entity acting on behalf
of the insurer receipt date of the medical billing form, regardless
of the date of payment.
(t) When an insurer, service company/TPA or any entity acting on
behalf of the insurer renders reimbursement following receipt of a
Determination or Final Order in response to a petition to resolve a
reimbursement dispute filed pursuant to Section 440.13(7), F.S., the
insurer shall:
1. Submit the required data elements to the Division within 45
calendar days of rendering reimbursement; and
2. Submit the data as a replacement submission pursuant to the
date-appropriate MEIG; and
3. Submit the cumulative, not the supplemental, payment information
at the line-item level utilizing EOBR 95 for each line-item
reflecting a payment amount differing from the payment amount
reported on the original submission; and
4. Report the “Date Insurer Received” as 22 days after the date the
Determination was received by certified mail, in instances where the
insurer has waived its rights under Section 120, F.S., or report the
“Date Insurer Received” as the date the carrier received the Final
Order by certified mail, in instances where the insurer has invoked
its rights pursuant to Section 120, F.S., whichever occurs first.
(u) When an insurer, service company/TPA, submitter or any entity
acting on behalf of the insurer has reported medical claims data to
the Division which was not required, the insurer shall withdraw the
previously reported data as described in the MEIG.
(v) When an insurer, service company/TPA, any entity acting on
behalf of the insurer renders reimbursement for multiple bills
received from a health care provider, the insurer shall report
required data elements to the Division for each individual bill,
including “Date Insurer Received” and “Date Insurer Paid”, submitted
by the health care provider and shall not combine multiple bills
received from a health care provider into a single medical bill data
submission (i.e. a single bill equals a single datum transmission).
