Division of Rehabilitation and Liquidation
Only one Proof of Claim (POC) form must be completed as part of the submission of your master claim. (A master claim is the aggregate amount due to a provider for outstanding charges for services provided on or before the date of liquidation).
Claims can only be submitted by the entity who owns the Federal Employer Identification Number (FEIN) on file with the IRS. If any distribution is made in this estate to medical providers, the checks will be issued only to FEIN owners. POCs were created according to FEINs and only one receiver claim number (“RCN”) was assigned to any FEIN.
If you billed the company in receivership using a FEIN that belongs to a provider or group that’s not you/your facility, your claim in this estate would be part of the claim for that entity. (e.g.: You bill using the FEIN for “ABC Medical Group”. “ABC” must submit a claim that includes your outstanding charges along with theirs.) The owner of the FEIN is responsible for distributing payment to the providers who billed using that FEIN.
In addition to a POC, the Receiver requires that you summarize your bills in an itemization table and submit the table as an electronic file (not a printed copy, PDF or other “static” document).
Note: All Medical Provider Master Claims require an itemization table.
The Receiver understands that the claims process can seem cumbersome. We’re asking you to prepare and send a summary because it will enable us to effectively evaluate your claim and control the costs incurred in administering this liquidation. Cost control directly affects how much money may become available for distribution.
Please read and follow the directions below.
STEP #1: Download the Medical Provider Itemization Table from our website by clicking here:
If you are unable to download the form, you can create your own form in either Microsoft Excel or Microsoft Access as long as it includes all of the information below:
TIP: Your medical bill processing software or accounting software may be able to produce a report with this same information.
|a. Company in Receivership: (Enter name from POC)|
|b. Claimant Name: (Enter name from POC)|
|c. RCN: (Enter from POC)|
|d. Claim Filing Deadline: (Enter from POC)|
|e. DOS (Date of Service-Block 24 A. /CMS-1500, Block 6/UB-04 MM/DD/YY)|
|f. Patient (Block 2/ CMS-1500, Block 38/UB-04 Lname, Fname)|
|g. Date of Birth (MM/DD/YY)|
|h. Amount Charged (with a bottom line total)|
A sample of a completed form can be found by clicking here
STEP #2: Create a consolidated * PDF file (Adobe.pdf) of all the bills (CMS-1500, UB-04) listed on the Medical Provider Itemization Table and in the order listed, please. (* “Consolidated” means a scrollable collection of images.)
Note: Paper submission of bills is limited to 20 or fewer pages.
STEP #3: Copy the completed Medical Provider Itemization Table and the consolidated PDF file of all the bills to a CD. Label the CD with the “Claimant Name” (taken from the POC) and the “RCN” (“Receiver Claim Number”-taken from the POC). If you need to send more than one CD, please also write on each CD label that the CD is part of a group (i.e., 1 of 3, 2 of 3…).
Mail the CD and completed Proof of Claim form to the following address:
Florida Department of Financial Services Receiver
Attention: Claims Section/ Master Claims
2020 Capital Circle SE, Ste 310
Tallahassee, FL 32301
Note: Claims submitted in a format other than what is specified may delay evaluation of your claim, result in the rejection of your claim in its entirety and/or require an offset against your claim for any administrative costs incurred.
Do you have questions?
Please see the contact information in the “Proof of Claim Form General Instructions” sheet on the back of the POC.
For questions or comments regarding this website, please click here.