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Florida Administrative Code (Last Updated: October 28, 2024) |
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69. Department of Financial Services |
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69L. Division of Workers' Compensation |
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69L-31. Utilization And Reimbursement Dispute Rules |
69L-31.004. Carrier Response to Petition for Resolution of Reimbursement Dispute Form and Requirements
1(1) The Carrier 4Response to Petition for Resolution of Reimbursement Dispute, Form DFS-F6-DWC-3160-0024, 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/PublicationsFormsManualReports/Forms/Default.htm or at 34https://www.flrules.org/Gateway/reference.asp?No=Ref-13338 36or by contacting 39the Department at (850)413-1613.
43(2) The Response Form is the only form accepted by the Department upon which a Carrier may submit its response, pursuant to Section 66440.13(7)(b), F.S., 68to a Petition Form. 72Instructions for submission of the Response Form are included on the bottom of the Response Form.
88(3) The Carrier must submit the Response Form, accompanied by all supporting documentation, to the Department in accordance with the timeframe set forth in Section 113440.13(7)(b), F.S.
115(a) If 117the Carrier issued a Notice of Denial under Rule 69L-56.4012, F.A.C., for any services or line items in dispute on the Petition Form, the Carrier must provide the same as supporting documentation.
149(b) If the Carrier 153disallowed payment for the line item in dispute based on Medical Necessity, the Carrier may submit any peer review or utilization review, that support the disallowance of payment, for inclusion in the case file sent to the Expert Medical Advisor (EMA) for review.
196(c) If the Carrier disallowed or adjusted the payment in the Notice of Disallowance or Adjustment because the Petitioner was not authorized to provide the services, all of the Carrier’s documentation, correspondence, and records evidencing authorization was not given to the Health Care Provider prior to the dates of service(s) or all of the Carrier’s documentation, records, and correspondence evidencing the Carrier responded to the request for authorization in accordance with paragraph (3)(d) or (3)(i) of Section 273440.13, F.S., 275if any.
277(4) Using a delivery method that provides confirmation of the date of delivery, the Carrier must provide to the Petitioner, at the Petitioner’s mailing address provided on the Petition Form, a copy of the Response Form and all supporting documentation submitted to the Department in response to the Petition Form. The Carrier must document the delivery tracking information in such detail that the Department can verify the Petitioner’s receipt of the Response Form and supporting documentation.
353(5) Any submission by a Carrier pursuant to Section 362440.13(7)(b), F.S., 364that does not include a completed Response Form, accompanied by all required items, will result in the issuance of a notice of deficiency by the Department. The Carrier 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 Petitioner. Failure to timely cure the deficiency and provide proof of service of the curative documentation upon the Petitioner will constitute failure to submit requested documentation to the Department and a waiver of all objections to the petition.
471Rulemaking 472Authority 473440.13(7)(e), 474440.591 FS. 476Law Implemented 478440.13(7), 479(11) FS. History–New 11-28-06, Formerly 48459A-31.004, 485Amended 8-2-21.
