(1) Definitions. As used in this rule:
(a) “Accurately Complete” or “Accurately Completed” means the form
submitted contains the information necessary to meet the
requirements of Chapter 440, F.S., and this rule.
(b) “Adjust” or “Adjusted” means payment is made with modification
to the information provided on the bill.
(c) “Ambulatory Surgical Center” is defined in Section 395.002(3),
F.S.
(d) “Billing” means the process by which a health care provider
submits a medical claim form or medical bill to an insurer, service
company/third party administrator or any entity acting on behalf of
the insurer, to receive reimbursement for medical services, goods or
supplies provided to an injured employee.
(e) “Catastrophic Event” means the occurrence of an event outside
the control of an insurer, submitter, service company/third party
administrator or any entity acting on behalf of the insurer, such as
an electronic data transmission failure due to a natural disaster or
an act of terrorism (including but not limited to cyber terrorism),
in which recovery time will prevent an insurer, submitter, service
company/third party administrator or any entity acting on behalf of
the insurer from meeting the filing and reporting requirements of
Chapter 440, F.S., and this rule. Programming errors, system
malfunctions or electronic data interchange transmission failures
that are not a direct result of a catastrophic event are not
considered to be a catastrophic event as defined in this rule. See
subsection (6)(d) for requirements to request approval of an
alternative method and timeline for medical report filing with the
Division due to a catastrophic event.
(f) “Charges” means the dollar amount billed.
(g) “Charge Master” means for hospitals a comprehensive listing of
all the goods and services for which the facility maintains a
separate charge, with the facility’s charge for each of the goods
and services, regardless of payer type and means for ASCs a listing
of the gross charge for each CPT procedure for which an ASC
maintains a separate charge, with the ASC’s charge for each CPT
procedure, regardless of payer type.
(h) “Claims-Handling Entity File Number” means the number assigned
to the claim file by the insurer or service company/third party
administrator for purposes of internal tracking.
(i) “Current Dental Terminology” (CDT) means the American Dental
Association’s reference document containing descriptive terms to
identify codes for billing and reporting dental procedures.
(j) “Current Procedural Terminology” (CPT) means the American
Medical Association’s reference document (HCPCS Level I) containing
descriptive terms to identify codes for billing and reporting
medical procedures and services.
(k) “Date Insurer Paid” or “Date Insurer Paid, Adjusted, Disallowed
or Denied” means the date the insurer, service company/third party
administrator or any entity acting on behalf of the insurer mails,
transfers or electronically transmits payment to the health care
provider or the health care provider representative. If payment is
disallowed or denied, “Date Insurer Paid” or “Date Insurer Paid,
Adjusted, Disallowed or Denied” means the date the insurer, service
company/third party administrator or any entity acting on behalf of
the insurer mails, transfers or electronically transmits the
appropriate notice of disallowance or denial to the health care
provider or the health care provider representative. See paragraph
(5)(1) for the requirement to accurately report the “date insurer
paid”.
(l) “Date Insurer Received” means the date that a Form 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 is in
the possession of the insurer, service company/third party
administrator or any entity acting on behalf of the insurer. See
paragraph (5)(l) for the requirement to accurately report the “date
insurer received”. If a medical bill meets any of the critiera in
paragraph (5)(j) of this rule and possession of the form is
relinquished by the insurer, service company/TPA or any entity
acting on behalf of the insurer by returning the medical bill to the
provider with a written explanation for the insurer’s reason for
return, then “date insurer received” shall not apply to the medical
bill as submitted.
(m) “Deny” or “Denied” means payment is not made because the service
rendered is treatment for a non-compensable injury or illness.
(n) “Department” means Department of Financial Services (DFS) as
defined in Section 440.02(12), F.S.
(o) “Disallow” or “Disallowed” means payment is not made because the
service rendered has not been substantiated for reasons of medical
necessity, insufficient documentation, lack of authorization or
billing error.
(p) “Division” means the Division of Workers’ Compensation (DWC) as
defined in Section 440.02(14), F.S.
(q) “Electronic Filing” means the computer exchange of medical data
from a submitter to the Division in the standardized format defined
in the Florida Medical EDI Implementation Guide (MEIG).
(r) “Electronic Form Equivalent” means the format, provided in the
Florida Medical EDI Implementation Guide (MEIG) to be used when a
submitter electronically transmits required data to the Division.
Electronic form equivalents do not include transmission by
facsimile, data file(s) attached to electronic mail, or
computer-generated paper-forms.
(s) “Electronically Filed with the Division” means the date an
electronic filing has been received by the Division and has
successfully passed structural and data-quality edits.
(t) “Entity” means any party involved in the processing,
adjudication or payment of medical bills on behalf of the insurer.
(u) “Explanation of Bill Review” (EOBR) means 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 this
rule.
(v) “Explanation of Bill Review Code” (EOBR Code) means a code
listed in subparagraph (5)(o)2. of this rule that describes the
basis for the reimbursement decision of an insurer, service
company/TPA or any entity acting on behalf of the insurer.
(w) “Florida Medical EDI Implementation Guide (MEIG)” is the Florida
Division of Workers’ Compensation’s reference document containing
the specific electronic formats and data elements required for
insurer reporting of medical data to the Division.
(x) “Healthcare Common Procedure Coding System National Level II
Codes (HCPCS)” (HCPCS) means the Centers for Medicare and Medicaid
Services’ (CMS) reference document listing descriptive codes for
billing and reporting professional services, procedures, and
supplies provided by health care providers.
(y) “Health Care Provider” is defined in Section 440.13(1)(h), F.S.
(z) “Home Health Agency” is defined in Section 400.462(12), F.S.
(aa) “Home Medical Equipment Provider” (sometimes referred to as
durable medical equipment (DME) provider) is defined in Section
400.925(7), F.S.
(bb) “Hospital” is defined in Section 395.002(12), F.S.
(cc) “ICD-9-CM International Classification of Diseases” (ICD-9) is
the U.S. Department of Health and Human Services’ reference document
listing the official diagnosis and inpatient procedure code sets.
(dd) “Insurer” is defined in Section 440.02(38), F.S.
(ee) “Insurer Code Number” means the number the Division assigns to
each individual insurer, self-insured employer of self-insured fund.
(ff) “Itemized Statement” means a detailed listing of goods,
services and supplies provided to an injured employee, including the
quantity and charges for each good, service or supply.
(gg) “Medical Bill” means the document or electronic equivalent
submitted by a health care provider to an insurer, service
company/TPA or any entity acting on behalf of the insurer for
reimbursement for services or supplies (e.g. DFS-F5-DWC-9,
DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider’s usual
invoice or business letterhead) as appropriate pursuant to paragraph
(4)(b) of this rule.
(hh) “Medically Necessary” or “Medical Necessity” is defined in
Section 440.13(1)(l), F.S.
(ii) “NDC Number” means the National Drug Code (NDC) number,
assigned under Section 510 of the Federal Food, Drug, and Cosmetic
Act, which identifies the drug product labeler/vendor, product, and
trade package size. The NDC number is an eleven-digit number that is
expressed in the universal 5-4-2 format and included on all
applicable reports with each of the three segments separated by a
dash (-).
(jj) “Nursing Home Facility” is defined in Section 400.021(12), F.S.
(kk) “Pay” or “Paid” means payment is made applying the applicable
reimbursement formula to the medical bill as submitted
(ll) “Physician” is defined in Section 440.13(1)(q), F.S.
(mm) “Primary Physician” means the treating physician responsible
for the oversight of medical care, treatment and attendance rendered
to an injured employee, to include recommendation for appropriate
consultations or referrals.
(nn) “Recognized Practitioner” means a non-physician health care
provider licensed by the Department of Health who works under the
protocol of a physician or who, upon referral from a physician, can
render direct billable services that are within the scope of their
license, independent of the supervision of a physician.
(oo) “Report” means any form related to medical services rendered,
in relation to a workers’ compensation injury, that is required to
be filed with the Division under this rule.
(pp) “Service Company/Third Party Administrator (TPA)” means a party
that has contracted with an insurer for the purpose of providing
services necessary to adjust workers’ compensation claims on the
insurer’s behalf.
(qq) “Service Company/Third Party Administrator (TPA) Code Number”
means the number the Division assigns to a service company,
adjusting company, managing general agent or third party
administrator.
(rr) “Submitter” means an insurer, service company/TPA, entity or
any other party acting as an agent on behalf of an insurer, service
company/TPA or any entity to fulfill any insurer responsibility to
electronically transmit required medical data to the Division.
(ss) “UB-04 Manual” means the National Uniform Billing Committee
Official UB-04 Data Specifications Manual 2009, which is the
reference document providing billing and reporting completion
instructions for the Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform
Bill, Rev. 2006).
(2) Forms Incorporated by Reference for Medical Billing, Filing and
Reporting.
(a) Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev.
08/05); Form DFS-F5-DWC-9-B (Completion Instructions for Form
DFS-F5-DWC-9: comprised of three sets of completion instructions;
one for use by health care providers, Rev. 3/1/2009; one each for
ambulatory surgical centers, and work hardening and pain management
programs), Rev. 1/1/07.
(b) Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical
Equipment & Supplies Form), Rev. 3/1/09.
(c) Form DFS-F5-DWC-11 (American Dental Association Dental Claim
Form, Rev. 2006); Form DFS-F5-DWC-11-B (Completion Instructions for
Form DFS-F5-DWC-11), Rev. 1/1/07.
(d) Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform
Medical Treatment/Status Reporting Form), Rev. 1/31/08.
(e) Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006);
Form DFS-F5-DWC-90-B (Completion Instructions for Form DFS-F5-DWC-90
for use by hospitals), Rev. 1/1/09. Form DFS-F5-DWC-90-C (Completion
Instructions for Form DFS-F5-DWC-90 for use by Ambulatory Surgical
Centers), New 1/1/09; Form DFS-F5-DWC-90-D (Completion Instructions
for Form DFS-F5-DWC-90 for use by Home Health Agencies), New 1/1/09;
DFS-F5-DWC-90-E (Completion Instructions for Form DFS-F5-DWC-90 for
use by Nursing Home Facilities), New 1/1/09.
(f) Obtaining Copies of Forms and Instructions.
1. A copy of the Form DFS-F5-DWC-9 can be obtained from the AMA web
site: https:catalog.ama-assn.org/Catalog. Completion instructions
(DFS-F5-DWC-9-B) the form can be obtained from the Department of
Financial Services/Division of Workers’ Compensation (DFS/DWC) web
site: http://www.myfloridacfo.com/WC/forms.html.
2. A copy of the Form DFS-F5-DWC-10 and completion instructions for
the form can be obtained from the DFS/DWC web site:
http://www.myfloridacfo.com/WC/forms.html.
3. A copy of the Form DFS-F5-DWC-11 can be obtained from the
American Dental Association web site: http://www.ada.org/.
Completion instructions for the form can be obtained from the
DFS/DWC web site: http://www.myfloridacfo.com/WC/forms.html.
4. A copy of the Form DFS-F5-DWC-25 and completion instructions can
be obtained from the DFS/DWC web site:
http://www.myfloridacfo.com/WC/forms.html.
5. A copy of the instructions for completion of Form DFS-F5-DWC-90
(Rev. 2006), Form DFS-F5-DWC-90-B (for hospitals) (Rev. 1/1/09),
Form DFS-F5-DWC-90-C (for ASCs) (New 1/1/09), Form DFS-F5-DWC-90-D
(for Home Health Agencies), Form DFS-F5-DWC-90-E (for Nursing Home
Facilities), New 1/1/09, can be obtained from the DFS/DWC web site:
http://www.myfloridacfo.com/WC/forms.html.
(g) In lieu of submitting a Form DFS-F5-DWC-10, when billing for
drugs or medical supplies, alternate billing forms are acceptable
if:
1. An insurer has approved the alternate billing form(s) prior to
submission by a health care provider, and
2. The form provides all information required to be submitted to the
Division, pursuant to the date-appropriate Florida Medical EDI
Implementation Guide (MEIG), on the Form DFS-F5-DWC-10, Form
DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted
as an alternate form.
(3) Materials Adopted by Reference. The following publications are
incorporated by reference herein:
(a) The American Medical Association Healthcare Common Procedure
Coding System, Medicare’s National Level II Codes (HCPCS), as
adopted in Rule 69L-7.020, F.A.C.
(b) The Current Procedural Terminology (CPT®), as adopted in Rule
69L-7.020, F.A.C.
(c) The Current Dental Terminology (CDT), as adopted in Rule
69L-7.020, F.A.C.
(d) The 2009 ICD-9-CM Professional for Hospitals, Volumes 1, 2 and
3, International Classification of Diseases, 9th Revision, Clinical
Modification, Copyright 2008, Ingenix, Inc. (American Medical
Association).
(e) The Physician ICD-9-CM 2009, Volumes 1 & 2, International
Classification of Diseases, 9th Revision, Clinical Modification,
Copyright 2008, Ingenix, Inc. (American Medical Association).
(f) The American Medical Association’s Guide to the Evaluation of
Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C.
(g) The Minnesota Department of Labor and Industry Disability
Schedule, as adopted in Rule 69L-7.604, F.A.C.
(h) The Florida Impairment Rating Guide, as adopted in Rule
69L-7.604, F.A.C.
(i) The 1996 Florida Uniform Permanent Impairment Rating Schedule,
as adopted in Rule 69L-7.604, F.A.C.
(j) National Uniform Billing Committee Official UB-04 Data
Specifications Manual 2010, version 4.00, July 2009, as adopted by
the National Uniform Billing Committee. A copy of this manual can be
obtained from the National Uniform Billing Committee web site:
http://www.nubc.org/become.html.
(k) The Florida Medical EDI Implementation Guide (MEIG), 2010. The
Florida Medical EDI Implementation Guide (MEIG), 2010 can be
obtained from the DFS/DWC web site:
http://www.myfloridacfo.com/WC/edi_med.html.
(l) The Florida Workers’ Compensation Reimbursement Manual for
Hospitals, Rule 69L-7.501, F.A.C.
(m) The Florida Workers’ Compensation Reimbursement Manual for
Ambulatory Surgical Centers, Rule 69L-7.100, F.A.C.
(n) The Florida Workers’ Compensation Health Care Provider
Reimbursement Manual, Rule 69L-7.020, F.A.C.
(4) Health Care Provider Responsibilities.
(a) Bill Submission/Filing and Reporting Requirements.
1. All health care providers are responsible for meeting their
obligations, under this rule, regardless of any business arrangement
with any entity under which claims are prepared, processed or
submitted to the insurer.
2. Each health care provider is responsible for submitting any form
completion information and supporting documentation requested by the
insurer that is in addition to the requirements of this rule and the
applicable reimbursement manual, when it is requested, in writing,
by the insurer at the time of authorization or upon receipt of
notification of emergency care.
3. Each health care provider shall resubmit a medical claim form or
medical bill with insurer requested documentation when the EOBR
provides an explanation for the disallowed service based on the
provider’s failure to submit requested documentation with the
medical bill.
4. Insurers and health care providers shall utilize only the Form
DFS-F5-DWC-25 for physician reporting of the injured employee’s
medical treatment/status. No other reporting forms may be used in
lieu of or supplemental to the Form DFS-F5-DWC-25.
a. The Form DFS-F5-DWC-25 does not replace physician notes, medical
records or Division-required medical reports.
b. All information submitted on physician notes, medical records or
Division-required medical reports must be consistent with
information documented on the Form DFS-F5-DWC-25.
5. All medical claim form(s) or medical bill(s) related to
authorized services shall be coded by the health care provider at
the highest level of specificity and submitted to the insurer,
service company/TPA or any entity acting on behalf of the insurer,
as a requirement for billing.
6. Medical claim form(s) or medical bill(s) may be electronically
filed or submitted via facsimile by a health care provider to the
insurer, service company/TPA or any entity acting on behalf of the
insurer, provided the insurer agrees.
7. When requested by the insurer, service company/TPA or any entity
acting on behalf of the insurer, a health care provider shall send
documentation that supports the medical necessity of the specific
services rendered and any other required documentation pursuant to
paragraph (4)(b) of this rule and the applicable reimbursement
manual.
8. Each health care provider is responsible for correcting and
resubmitting any billing forms returned by an insurer, service
company/TPA or any entity acting on behalf of the insurer pursuant
to paragraph (5)(j) of this rule.
9. Each hospital and ambulatory surgical center shall maintain its
charge master and shall produce relevant portions when requested for
the purpose of verifying its usual charges pursuant to Section
440.13(12)(d), F.S.
10. A health care provider shall bill multiple services, rendered on
the same date of service, on a contiguous bill; provided however,
nothing herein shall prevent a physician from selling, assigning or
otherwise factoring a claim for the provision of pharmacy related
services to a third party.
(b) Special Billing Requirements.
1. When anesthesia services are billed on a Form DFS-F5-DWC-9,
completion of the form must include the CPT® code and the “P” code
(physical status modifier), which correspond with the procedure
performed, in Field 24D. Anesthesia health care providers shall
enter the date of service and the 5-digit qualifying circumstance
code, which correspond with the procedure performed, in Field 24D on
the next line, if applicable.
2. When a Certified Registered Nurse Anesthetist (CRNA) provides
anesthesia services, the CRNA shall bill on a Form DFS-F5-DWC-9 for
the services rendered and enter his/her Florida Department of Health
ARNP license number in Field 33b, regardless of the employment
arrangement under which the services were rendered, or the party
submitting the bill.
3. Recognized practitioners, except physician assistants, advanced
registered nurse practitioners, certified registered nurse
anesthetists, who are salaried employees of an authorized treating
physician and, who render direct billable services for which
reimbursement is sought from an insurer, service company/TPA or any
entity acting on behalf of the insurer, service company/TPA, shall
report and bill for such services on a Form DFS-F5-DWC-9 by entering
the employing physician’s Florida Department of Health license
number in Field 33b on the Form DFS-F5-DWC-9.
4. For hospital billing, the following special requirements apply:
a. Inpatient billing – Hospitals shall, in addition to filing a Form
DFS-F5-DWC-90:
I. Attach an itemized statement with charges based on the facility’s
Charge Master; and
II. Submit all specifically requested and additional documentation
requested at the time of authorization; and
III. Bill professional services provided by a physician, physician
assistant, advanced registered nurse practitioner, or registered
nurse first assistant on the Form DFS-F5-DWC-9, regardless of
employment arrangement;
IV. Make written entry “implant(s)” followed by the reimbursement
amount calculated pursuant to Rule 69L-7.501, F.A.C., in Form
Locator 80 of Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90,
or certification required pursuant to Rule 69L-7.501, F.A.C.
b. Outpatient billing – Hospitals shall in addition to filing a Form
DFS-F5-DWC-90:
I. Enter the CPT®, HCPCS or workers’ compensation unique code and
the applicable CPT® or HCPCS modifier code in Form Locator 44 on the
Form DFS-F5-DWC-90, when required pursuant to the UB-04 Manual; and
II. Make written entry “scheduled” or “non-scheduled” in Form
Locator 80 of Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90,
when billing outpatient surgery or outpatient surgical services; and
III. Attach an itemized statement with charges based on the
facility’s Charge Master; and
IV. Submit all applicable documentation required pursuant to Rule
69L-7.501, F.A.C.;
V. Bill professional services provided by a physician or recognized
practitioner on the Form DFS-F5-DWC-9, regardless of employment
arrangement;
5. A certified, licensed physician assistant, and registered nurse
first assistant who provides services as a surgical assistant, in
lieu of a second physician, shall bill on a Form DFS-F5-DWC-9
entering the CPT® code(s) plus modifier(s), which represent the
service(s) rendered, in Field 24D, and must enter his/her Florida
Department of Health license number in Field 33b.
6. Ambulatory Surgical Centers (ASCs) shall bill as follows:
a. For dates of service up to and including 07/07/2010, ASCs shall
bill on Form DFS-F5-DWC-9 using the American Medical Association’s
CPT® procedure codes, or using the workers’ compensation unique
procedure code 99070 with required modifiers and shall bill charges
based on the ASC’s Charge Master except when billing for procedure
code 99070.
b. For dates of service on or after 07/08/2010, Ambulatory Surgical
Centers shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®,
HCPCS or workers’ compensation unique code and the applicable CPT®
or HCPCS modifer code in Form Locator 44 for each service rendered.
ASCs shall bill charges based on the ASC’s Charge Master except when
billing for surgical implants, associated disposable instrumentation
and applicable shipping and handling. ASCs shall use Revenue Center
Code 0278 and workers’ compensation unique code(s) with required
modifier(s) pursuant to Rule 69L-7.100, F.A.C., when billing for
surgical implants, associated disposable instrumentation, and
applicable shipping and handling pursuant to Rule 69L-7.100, F.A.C.
ASC medical bills shall be accompanied by all applicable
documentation or certification required pursuant to Rule 69L-7.100,
F.A.C.
7. Home Health Agencies (HHAs) shall bill on Form DFS-F5-DWC-90.
a. For dates of service up to and including 07/07/2010, HHAs shall
bill on letterhead or invoice.
b. For dates of service on or after 07/08/2010, HHAs shall bill on
Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’
compensation unique codes and the applicable CPT® or HCPCS modifer
code in Form Locator 44 for each service rendered.
8. Nursing Home Facilities shall bill on Form DFS-F5-DWC-90.
a. For dates of service up to and including 07/07/2010, Nursing Home
Facilities shall bill on letterhead or invoice.
b. For dates of service on or after 07/08/2010, Nursing Home
Facilities shall bill on Form DFS-F5-DWC-90 and shall enter the
CPT®, HCPCS or workers’ compensation unique code and the applicable
CPT® or HCPCS modifer code in Form Locator 44 for each service
rendered.
9. Federal Facilities shall bill on their usual form.
10. Out-of-State health care providers shall bill on the applicable
medical bill form pursuant to paragraph (4)(c) of this rule.
11. Dental Services.
a. Dentists shall bill for services on Form DFS-F5-DWC-11.
b. Oral surgeons shall bill for oral and maxillofacial surgical
services on a Form DFS-F5-DWC-9. Non-surgical dental services shall
be billed on Form DFS-F5-DWC-11.
c. When dispensing medications, dentists and oral surgeons shall
submit charges on the forms specified in paragraphs 11.a. and 11.b.
above.
12. Pharmaceutical(s), Durable Medical Equipment and Home Medical
Equipment or Supplies.
a. When dispensing commercially available medicinal drugs commonly
known as legend or prescription drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format, in Field 9, with each
segment separated by a dash (-).
II. Physicians, physician assistants, or ARNPs shall bill on Form
DFS-F5-DWC-9 and shall enter the NDC number, in the universal 5-4-2
format, in Field 24D, with each segment separated by a dash (-). The
workers’ compensation unique code DSPNS must be entered in addition
to the NDC number in Field 24D. DME and medical supplies dispensed
by a physician or recognized practitioner during an office visit
must be billed on the DWC-9.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
b. When dispensing medicinal drugs which are compounded and the
prescribed formulation is not commercially available:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
workers’ compensation unique code COMPD in Field 9.
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9 and shall enter the workers’ compensation unique code
COMPD in form Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
c. When dispensing over-the-counter drug products:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format in form Field 9, with each
segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9, shall enter the NDC number in the universal 5-4-2
format, in Field 24D, with each segment separated by a dash
(-).Medication dispensed by a physician or recognized practitioner
during an office visit must be billed on the DWC-9.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
d. When administering or dispensing injectable drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format, in form Field 9, with
each segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on a Form
DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field
24D. When an appropriate HCPCS “J” code is not available for the
injectable drug, enter the NDC number, in the universal 5-4-2 format
in form Field 24D with each segment separated by a dash (-).
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
e. When dispensing durable medical equipment (DME):
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
applicable HCPCS code in Field 21 on form revision 3/1/2009.
II. Physicians and recognized practitioners shall bill on Form
DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and
attach documentation indicating the actual cost of the supply.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable
revenue codes.
IV. Home Medical Equipment Providers shall bill on Form
DFS-F5-DWC-10 and shall enter the applicable HCPCS code in form
Field 21 on form revision 3/1/2009.
f. When dispensing medical supplies which are not incidental to a
service or procedure:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
applicable HCPCS code in Field 21 on form revision 3/1/2009.
II. Physicians and recognized practitioners shall bill on Form
DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and
attach documentation indicating the actual cost of the supply.
III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable
revenue codes.
IV. Home Medical Equipment Providers shall bill on Form
DFS-F5-DWC-10 for DME supplies prescribed by a physician or
recognized practitioner, and shall enter the applicable HCPCS code
in Field 21 on form revision 3/1/2009.
g. Pharmacists who provide Medication Therapy Management Services
shall bill for these services on Form DFS-F5-DWC-9 by entering the
appropriate CPT® code(s) 99605, 99606 or 99607 that represent the
service(s) rendered in form Field 24D, shall enter their Florida
Department of Health license number in Field 33b and shall submit a
copy of the physician’s written prescription with the medical bill.
h. Pharmacists and medical suppliers may only bill on an alternate
to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the
alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90
shall not be approved for use as the alternate form.
13. Physicians billing for a failed appointment for a scheduled
independent medical examination (when the injured employee does not
report to the physician office as scheduled) shall bill worker’s
compensation unique code 99456-CN on the DFS-F5-DWC-9.
14. Health care providers receiving reimbursement under any payment
plan (pre-payment, prospective pay, capitation, etc.) must
accurately complete the Form DFS-F5-DWC-9 and submit the form to the
insurer.
15. Parties that are not physicians or recognized practitioners
authorized by an insurer to render services reimbursable under
workers’ compensation shall bill on their invoice or letterhead.
These parties shall not bill using Forms DFS-F5-DWC-9,
DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.
(c) Bill Completion.
1. Bills shall be legibly and accurately completed by all health
care providers, regardless of location or reimbursement methodology,
as set forth in this section and paragraph (4)(b) of this rule.
2. Billing elements required by the Division to be completed by a
health care provider are identified in Form DFS-F5-DWC-9-B
(completion instructions) available at the following websites:
a. http://www.myfloridacfo.com/WC/pdf/DWC-9instrHCP_3-1-09.pdf when
submitted by Licensed Health Care Providers;
b. http://www.myfloridacfo.com/WC/pdf/DWC-9instrASC_1-1-07.pdf when
submitted by Ambulatory Surgical Centers for dates of service up to
and including 03/21/10;
c. http://www.myfloridacfo.com/WC/pdf/DWC-9instrWHPM_1-1-07.pdf when
submitted by Work Hardening and Pain Management Programs.
3. Billing elements required by the Division to be completed for
Pharmaceutical or Medical Supplier Billing are identified in Form
DFS-F5-DWC-10 (completion instructions) available at website:
http://www.myfloridacfo.com/WC/forms.html.
4. Billing elements required by the Division to be completed for
Dental Billing are identified in Form DFS-F5-DWC-11-B (completion
instructions) available at website:
http://www.myfloridacfo.com/WC/forms.html.
5. Billing elements required by the Division to be completed for
Form DFS-F5-DWC-90 are identified in the UB-04 Manual, and as
follows;
a. For Hospital billing, Form DFS-F5-DWC-90-B (UB-04) – B Completion
Instructions, Rev. 1/1/2009 and subparagraph (4)(b)4. of this rule.
b. For Ambulatory Surgical Center billing, Form DFS-F5-DWC-90-C
(UB-04) – C Completion Instructions, New 1/1/2009 and subparagraph
(4)(b)6. of this rule.
c. For Home Health Agency billing, Form DFS-F5-DWC-90-D (UB-04) – D
Completion Instructions, New 1/1/2009 and subparagraph (4)(b)7. of
this rule.
d. For Nursing Home Facility billing, Form DFS-F5-DWC-90-E (UB-04) –
E Completion Instructions, New 1/1/2009 and subparagraph (4)(b)8. of
this rule.
6. A health care provider shall submit additional data elements or
supporting documentation that are required by the insurer that have
been requested in writing pursuant to paragraph (5)(b) of this rule.
(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 medical bills 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 upon
receipt of notification of emergency care, an insurer shall notify
each health care provider, in writing, of data elements or
supporting documentation that are necessary for reimbursement
determinations that are in addition to the requirements of this rule
and the applicable reimbursement manual.
(c) At the time of authorization for medical service(s), or upon
receipt of notification of emergency care, an insurer shall inform
out-of-state health care providers of the specific reporting,
billing and submission requirements contained in subsection (4)
(Health Care Provider Responsibilities) of this rule and provide
in-state and out-of-state health care providers 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. No other reporting forms may 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 Bill Processing Report”, as
defined in the date-appropriate 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-appropriate Florida Medical EDI Implementation Guide (MEIG) and
subparagraphs (4)(c)2.-5. of this rule. Additionally, an insurer or
entity acting on behalf of an insurer shall be responsible for
correcting previously accepted data that is deemed inaccurate by the
Division through monitoring, auditing, investigation or analysis,
and resubmitting the corrected and accurate data in accordance with
the requirements set forth in paragraph (6)(e) 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 web site:
http://www.myfloridacfo.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),
NDC number 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) or NDC
number 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)(l) 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 is deficient according to 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 within twenty-one (21)
days of the “Date Insurer Received” with a written statement
identifying the deficiency criteria under which the medical bill is
being returned. 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, which
must accompany the returned bill must include all deficiency
criteria upon which the return of the medical bill are based.
3. If the deficiency criteria upon which the return of the medical
bill is based includes any of the deficiency criteria in
sub-subparagraphs (5)(j)5.d.-g. 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 deficiency criteria set
forth in subparagraph (5)(j)5. of this rule.
5. The deficiency 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 illegible on the
medical bill; or
g. Billing information required by this rule is omitted or
incomplete 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)(t) 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)(t) 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)(t) 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)(t) 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 federal
facilities billing on their usual form, for duplicate medical bills,
for medical bills outside the authority of Florida’s workers’
compensation system, or for health care providers in subparagraph
(4)(b)15. 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. When reporting production data with the Medical Data System in
the Claim Record Layout-Revision “E” as required in paragraph (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:
06 – Payment disallowed: location of service(s) is not consistent
with the level of service(s) billed.
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 or notice provided for emergency
treatment pursuant to Section 440.13(3), F.S.
34 – Payment disallowed; no modification to the information provided
on the medical bill. No payment made pursuant to contractual
arrangement.
38 – Payment disallowed: insufficient documentation: documentation
does not support this supply was dispensed to the patient.
39 – Payment disallowed: insufficient documentation: documentation
does not support this medication was dispensed to the patient.
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.
(Insurer must specify missing components of evaluation and
management code description.)
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 or
certification 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: specific
documentation requested in writing at the time of authorization not
submitted with the medical bill. (Insurers must specify omitted
documentation.)
51 – Payment disallowed: insufficient documentation: required
DFS-F5-DWC-25 not submitted.
52 – Payment disallowed: insufficient documentation: supply(ies)
incidental to the procedure. (Insurer must specify which supply is
incidental to which 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.
59 – Payment disallowed: billing error: Correct Coding Initiative
guidelines indicate this code is mutually exclusive to code XXXXX
billed for service(s) provided on the same day (Insurer must specify
inclusive procedure code).
60 – Payment disallowed: billing error: line item service previously
billed and reimbursement decision previously rendered.
61 – Payment disallowed: billing error: duplicate bill. (Shall not
be transmitted electronically to the Division.)
62 – Payment disallowed: billing error: incorrect procedure,
modifier, units, supply code or NDC number.
63 – Payment disallowed: billing error: service billed is integral
component of another procedure code. (Insurer must specify inclusive
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.
66 – Payment disallowed: billing error: omitted procedure, modifier,
units, supply code or NDC number.
67 – Payment disallowed: billing error: Same service billed multiple
times on same date of service.
68 – Payment disallowed: billing error: Rental value has exceeded
purchase price per written fee agreement.
69 – Payment disallowed: billing error: Correct Coding Initiative
guidelines indicate this code is a comprehensive component of code
XXXXX billed for service(s) provided on the same day (Insurer must
specify inclusive procedure code.)
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: specific
documentation requested in writing at the time of authorization not
submitted with the medical bill.
80 – Payment adjusted: billing error: correction of procedure,
modifier, supply code, units, or NDC number.
81 – Payment adjusted: billing error: payment modified pursuant to a
charge audit.
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.
85 – Payment adjusted: no modification to the information provided
on the medical bill. Payment made pursuant to a fee agreement
between the health care provider and the carrier.
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 written contractual
arrangement (network or PPO name required).
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.
96 – Paid: Payment made pursuant to a write-off by a health care
provider self-insured employer.
(p) An insurer, service company/TPA, submitter or any entity acting
on behalf of the insurer shall make available to the Division, 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
detailing the adjudication of the submitted bill by line item,
utilizing only the EOBR codes and code descriptors per line item, as
set forth in paragraph (o) of this section, and shall include the
insurer name, Division issued insurer number and corresponding
insurer mailing address. However, an insurer may choose to append an
internal reason code to the EOBR it submits to the health care
provider, when utilizing an EOBR code set forth in paragraph (o)
that includes a code descriptor requiring the insurer to provide
additional specification. 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 Chapter 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 Chapter 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.
(6) Insurer Electronic Medical Report Filing to the Division.
(a) Effective 3/16/05, all required medical reports shall be
electronically filed with the Division by all insurers.
(b) Required data elements shall be submitted in compliance with the
instructions and formats as set forth in the date-appropriate
Florida Medical EDI Implementation Guide (MEIG).
(c) The Division will notify the insurer on the “Medical Bill
Processing Report” of the corrections necessary for rejected medical
reports to be electronically re-filed with the Division. An insurer
shall correct and re-file all rejected medical reports to meet the
filing requirements of paragraph (5)(e) of this rule.
(d) Submitters who experience a catastrophic event resulting in the
insurer’s failure to meet the reporting requirements in paragraph
(5)(e) of this rule, shall submit a written or electronic request
within 15 business days after the catastrophic event to the Division
for approval to submit in an alternative reporting method and an
alternative filing timeline. The request shall contain a detailed
explanation of the nature of the event, date of occurrence, and
measures being taken to resume electronic submission. The request
shall also provide an estimated date by which electronic submission
of affected EDI filings will be resumed. Approval must be obtained
from the Division’s Office of Data Quality and Collection, 200 East
Gaines Street, Tallahassee, Florida 32399-4226. Approval to submit
in an alternative reporting method and an alternative filing
timeline shall be granted by the Division if a catastrophic event
prevents electronic submission.
(e) When filing any medical report replacement that corrects a
rejected medical report or replaces a previously accepted medical
report, the submitter shall use the same control number as the
original submission. The replacement report submission shall contain
all information necessary to process the medical report including
all services and charges from the medical bill as billed by the
health care provider and all payments made by the insurer to the
health care provider. Additionally, an insurer or entity acting on
behalf of an insurer shall follow the EDI medical bill replacement
methodology specified in the 2010 Florida Medical EDI Implementation
Guide (MEIG), using Report Reason Code “03” (See Appendix C), after
being notified by the Division that data previously accepted has
been deemed inaccurate and responding to a written request from the
Division to review, correct, and re-submit accurate data. Each
Division written request shall have a specified timeline to which
the insurer or entity acting on behalf of an insurer shall adhere.
(f) Each insurer shall be responsible for accurately completing the
electronic record-layout programming requirements for the reporting
of the Form DFS-F5-DWC-9 Record Layout – Revision “E”, Form
DFS-F5-DWC-10 Record Layout – Revision “E”, Form DFS-F5-DWC-11
Record Layout – Revision “E” and Form DFS-F5-DWC-90 Record Layout –
Revision “E” in accordance with the Florida Medical EDI
Implementation Guide (MEIG), 2010, to the Division in accordance
with the phase-in schedule as denoted below in subparagraphs 1., 2.,
and 3. of this section. The electronic record layout for Form
DFS-F5-DWC-90 in the MEIG 2010 adds the new fields for Provider
Facility National Provider Identification (NPI) number, Florida
Agency for Health Care Administration facility license number for
Ambulatory Surgical Centers, Home Health Care Agencies, and Nursing
Home Facilities, procedure, service or supply code modifier 2 as
billed by the provider, procedure, service or supply code modifier 3
as billed by the provider, procedure, service or supply code
modifier 4 as billed by the provider, procedure, service or supply
code as paid by the insurer, procedure, service or supply code
modifier 1 as paid by the insurer, procedure, service or supply code
modifier 2 as paid by the insurer, procedure, service or supply code
modifier 3 as paid by the insurer, procedure, service or supply code
modifier 4 as paid by the insurer, and the line item amount paid by
the insurer.
1. Submitters who have been approved for reporting production data
with the Medical Data System (Record Layout – Revision “D”), between
04/01/2007 and 06/15/2007 shall begin testing on 03/01/2010 and
shall complete the testing process with the new Revision “E” record
layouts no later than 04/12/2010.
2. Submitters who have been approved for reporting production data
with the Medical Data System (Record Layout – Revision “D” ),
between 06/16/2007 and 08/07/2007 shall begin testing on 04/13/2010
and shall complete the testing process with the new Revision “E”
record layouts no later than 05/25/2010.
3. Submitters who have been approved for reporting production data
with the Medical Data System (Record Layout – Revision “D” ),
between 08/08/2007 and the effective date of this rule shall begin
testing on 05/26/2010 and shall complete the testing process with
the new Revision “E” record layouts no later than 07/07/2010.
4. The Division will, resources permitting, allow submitters that
volunteer to complete the test transmission processes earlier than
the schedule denoted above. Each voluntary submitter shall have six
weeks to complete test transmission to production transmission
processes, for all electronic form equivalents, that comply with
requirements set forth in the Florida Workers’ Compensation Medical
EDI Implementation Guide (MEIG), 2010.
(g) All submitters shall be in production with the new Revision “E”
record layouts on 07/08/2010.
(h) Submitters who do not accurately complete and maintain
electronic record-layout programming requirements of this rule shall
not submit medical reports electronically until the submitter has
been approved for reporting production data with the Medical Data
System as necessary to meet the filing requirements of paragraph
(5)(e) of this rule.
(7) Insurer Administrative Penalties and Administrative Fines for
Untimely Health Care Provider-Payment or Disposition of Medical
Bills.
(a) The Department shall impose insurer administrative penalties for
failure to comply with the payment, adjustment, disallowance or
denial requirements pursuant to Section 440.20(6)(b), F.S. Timely
performance standards for timely payments, adjustments and payments,
disallowances or denials, reported on Forms DFS-F5-DWC-9,
DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90, shall be calculated
and applied on a monthly basis for each separate form category that
was received within a specific calendar month. Such insurer
penalties shall be determined according to the penalty schedule in
paragraph (7)(b) of this rule.
(b) Pursuant to Section 440.185(9), F.S., the Department shall
impose insurer administrative fines for failure to comply with the
submission, filing or reporting requirements of this rule. Insurer
administrative fines shall be applied as follows:
1. Calculated on a monthly basis for each separate form category
(Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90)
received and accepted by the Division within a specific calendar
month; and
2. Insurers are required to report all medical reports timely
pursuant to paragraph (5)(e) of this rule. Insurers that fail to
submit a minimum of 95% of all medical reports timely are subject to
an administrative fine. Each untimely filed medical report which
falls below the 95% requirement is subject to the following penalty
schedule:
a. 1 – 30 calendar days late $5.00;
b. 31 – 60 calendar days late $10.00;
c. 61 – 90 calendar days late $25.00;
d. 91 or greater calendar days late $100.00.
3. Each medical report that does not pass the electronic reporting
edits shall be rejected by the Division and considered not filed
pursuant to paragraph (5)(e) of this rule. If the medical report
remains rejected and not corrected, resubmitted and accepted by the
Division for greater than 90 days, an administrative fine shall be
assessed in the amount of $100.00 for each such medical report.
Rejected and not resubmitted medical reports will not be included in
the 95% timely reporting requirement.
4. Untimely filed medical reports for a given month will be excluded
from the administrative fine set forth in subparagraph (7)(b)3.
above as falling within the performance standard between 100% and
95% in the following order:
a. Medical Reports filed 1 – 30 calendar days late; then
b. Medical Reports filed 31 – 60 calendar days late; then
c. Medical Reports filed 61 – 90 calendar days late; then
d. Medical Reports filed 91+ calendar days late.
Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5),
440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09,
440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b),
(d), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New
1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05,
6-25-06, 3-8-07, 1-12-10.
