Non-Payment Issues

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A non-payment issue arises when an accurately completed medical bill is submitted to a workers’ compensation insurer for authorized medical treatment and/or service(s) and the insurer does not, within 45 days following receipt of the medical bill:

• Respond to the health care provider’s submitted medical bill (EOBR), or
• Tender payment to the submitted health care provider.

Pursuant to Rule 69L-7.602(5), F.A.C. and Section 440.20(2)(b), Florida Statutes, a workers’ compensation insurer must pay, disallow, adjust or deny reimbursement within 45 days of receipt of an accurately completed medical bill. The insurer must notify the provider, within the same time frame, of the insurer’s reimbursement decision by issuing an Explanation of Bill Review (EOBR) to explain the insurer’s reason(s) for the reimbursement decision.

If the workers’ compensation insurer failed to issue payment, failed to issue an EOBR or failed to file a DFS-F2-DWC-12 with the Division, pursuant to Rule 69L-3.012, Florida Administrative Code, within 45 days following receipt of an accurately completed medical bill, the health care provider may file a non-payment complaint with the Division of Workers’ Compensation, Office of Medical Services. The non-payment complaint, for each medical bill, must be in writing and must include the following documentation:

• A legible copy of the accurately completed medical bill;
• An itemized Billing Statement (Hospital Bill);
• An accurately completed DFS-F5-DWC-25 for each date of service (physician encounter);
• Proof of submission or mailing of the medical bill to the insurer; and
• A call log or any communication between the health care provider and the carrier regarding payment of the outstanding charges for medical service(s) or treatment.