69L-31.003. Petition for Resolution of Reimbursement Dispute Form and Requirements

(1) The Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0023, effective 07/2021, is incorporated by reference herein. This form may be obtained on the Department’s website at https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm or at https://www.flrules.org/Gateway/reference.asp?No=Ref-13337 or by contacting the Department at [phone].

(2) A petition to contest Carrier disallowance or adjustment of payment pursuant to Section 440.13(7)(a), F.S., must be made on the Petition Form. The Department will not accept any other form or document in lieu of the Petition Form.

(3) The Petitioner must submit the Petition Form to the Department within the timeframe set forth in Section 440.13(7)(a), F.S., and must include with the Petition Form the documents listed below that support the allegations contained in the Petition Form:

(a) A copy of each Notice of Disallowance or Adjustment received from the Carrier and, if applicable, proof of the date of receipt, as required by subsection 69L-31.008(1), F.A.C.;

(b) A copy of all medical bill(s) or request(s) for reimbursement sent to the Carrier for which payment was disallowed or adjusted by the Carrier on each Notice of Disallowance or Adjustment;

(c) A copy of all documentation submitted to the Carrier in support of the medical service(s), bill(s), or request(s) for reimbursement that are subject to the dispute;

(d) If the services provided in the Notice of Disallowance or Adjustment were alleged by the Carrier as being reimbursed pursuant to a contract:

1. Documentation substantiating the contract was in effect for the line item(s) in dispute and the provision which governs reimbursement for the services if Petitioner is disputing payment was made at an amount that is less than the amount prescribed in such a contract; or

2. Documentation substantiating the contract was in effect and the terms of the contract which evidence its inapplicability to the line item(s) in dispute if Petitioner is disputing the applicability of the contract to the line item(s) in dispute; or

3. Petitioner shall indicate on question 4 of the Petition Form that no contract existed between parties if the Petitioner disputes that a contract ever existed; or

4. Documentation substantiating that there was no contract in effect for the line item(s) in dispute if Petitioner disputes that a contract, which had been in effect at one time, was no longer in effect for the line item(s) in dispute;

(e) If the Medical Necessity of the services in the Notice of Disallowance or Adjustment are being disputed, supporting medical notes and records for the line item(s) in dispute must be provided; a Letter of Medical Necessity signed by the Health Care Provider who provided the services in the contested line item(s) in the Notice of Disallowance or Adjustment describing the Medical Necessity of the services may be provided in addition to the supporting medical notes and records;

(f) If the authorization for the services in the Notice of Disallowance or Adjustment are being disputed, all of the Petitioner’s documentation, records, and correspondence related to the authorization or request for authorization, if any; and

(g) Any additional documents or records that support the allegations contained in the Petition Form. 

(4) If the Petitioner does not submit a completed Petition Form, accompanied by all of the required items, the Department will notify the Petitioner of the deficiency in submission. The Petitioner will have twenty (20) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Department the items specified in the Department’s notice along with proof of proper service of the curative documentation upon the Carrier and all affected parties. If the Department does not receive the curative documentation and proof of service of the curative documentation upon the Carrier and all affected parties within twenty (20) calendar days after Petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (11) FS. History–New 11-28-06, Formerly 59A-31.003, Amended 8-2-21.