69L-7.750. Insurer Electronic Medical Report Filing to the Division

(1) Effective 3/16/05, all required medical reports shall be electronically filed with the Division by all insurers.

(2) Required data elements shall be submitted in compliance with the MEIG.

(3) The Division will notify the Sender on the “Medical Bill Acknowledgement” of the corrections necessary for rejected medical reports to be electronically re-filed with the Division. An insurer shall ensure all rejected medical reports are corrected and resubmitted successfully to meet the filing requirements of subsection 69L-7.750(5), F.A.C.

(4) Any Sender who experiences a catastrophic event resulting in the insurer’s failure to meet the reporting requirements in subsection 69L-7.740(5), F.A.C., 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 electronic data interchange or EDI filings, as defined in the MEIG, will be resumed. Approval shall be obtained from the Division’s Bureau 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 transmission.

(5) When filing any medical report replacement that corrects or replaces a previously accepted medical report, the sender shall use the same control number as the original transaction using bill submission reason code “03”. The replacement report 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 a claim administrator or entity acting on behalf of an insurer to the health care provider. Additionally, after being notified by the Division that data has been accepted with errors or that data previously accepted has been deemed inaccurate, a claim administrator or entity acting on behalf of an insurer shall correct or replace the inaccurate data, using the same control number as the original transaction and using bill submission reason code “03”. The insurer or the entity acting on behalf of the insurer shall respond 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.

(6) Each insurer shall be responsible for ensuring the accurate completion of the Medical EDI Bill Record Layouts Revision F for Records 09, 10, 11 and 90 as defined in and in accordance with the MEIG’s phase-in schedule, as denoted below.

(a) Senders with Sender FL ID  numbers 001 – 199, as defined in the MEIG, shall begin testing 150 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 195 days after the effective date of this rule.

(b) Senders with Sender FL ID numbers 200 – 899, as defined in the MEIG, shall begin testing 195 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 240 days after the effective date of this rule.

(c) Senders with Sender FL ID numbers 900 and above, as defined in the MEIG, shall begin testing 240 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 285 days after the effective date of this rule.

(d) The Division will, resources permitting, allow senders that volunteer to complete the test transmission processes earlier than the schedule denoted above. Each voluntary sender shall still have 45 days from the start date of testing to complete the test transmission to production transmission processes, for all Medical EDI Bill Records, that comply with requirements set forth and defined in the MEIG.

(7) Senders who do not accurately complete the testing requirements in accordance with the MEIG shall not submit Revision F medical Reports electronically until having been approved for reporting production data with the Division as necessary to meet the filing requirements of subsection 69L-7.750(5), F.A.C.

(8)(a) In the medical bill claims-handling process, the receipt of medical bills may be based upon receipt by the insurer or “entity” acting on behalf of an insurer. Likewise, the payment of medical bills may be based upon payment by the insurer or “entity” acting on behalf of an insurer. Therefore, to properly reflect “Date Insurer Received Bill” and “Date Insurer Paid Bill,” the insurer or entity acting on behalf of the insurer, shall be limited to the receipt and payment options of this subpart for the reporting of a medical bill:

1. Both receipt and payment of medical bills are handled by the insurer. This option may be utilized only when the “Date Insurer Received Bill” is the date the insurer gained possession of the health care provider’s medical bill, and the “Date Insurer Paid Bill” is the date the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. 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.

2. 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 Bill” 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 Bill” is the date an entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

3. 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 Bill” is the date the insurer gained possession of the health care provider’s medical bill, and the “Date Insurer Paid Bill” is the date an entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. 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.

4. 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 Bill” 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 Bill” is the date the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

(b) 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.

(c) The option in paragraph 69L-7.750(8)(a), F.A.C., selected by the insurer shall be identified on each medical report electronic submission to the Division and shall utilize the following coding methodology:

1. If the “Date Insurer Received Bill” is the date the insurer gains possession of the health care provider’s medical bill and the “Date Insurer Paid Bill” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 1 shall be transmitted on each individual electronic form equivalent transaction (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the Florida Medical EDI Implementation Guide (MEIG)). When submitting Payment Code “x” 1 to the Division, the insurer is declaring that no “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling processes related to “Date Insurer Received Bill” or “Date Insurer Paid Bill.”

2. If the “Date Insurer Received Bill” 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 Bill” 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 shall be transmitted on each individual electronic form equivalent transaction (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG). When submitting Payment Code “x” 2 to the Division, the insurer is declaring that the specified “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is acting on behalf of the insurer for purposes of the medical bill claims-handling processes related to “Date Insurer Received Bill” and “Date Insurer Paid Bill.”

3. If the “Date Insurer Received Bill” is the date the insurer gains possession of the health care provider’s medical bill and “Date Insurer Paid Bill” 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 shall be transmitted on each individual electronic form equivalent transaction (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG). When submitting Payment Code “x” 3 to the Division, the insurer is declaring that no “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling process related to “Date Insurer Received Bill.”

4. If the “Date Insurer Received Bill” 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 Bill” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 4 shall be transmitted on each individual form electronic form equivalent transaction (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG). When submitting Payment Code “x” 4 to the Division, the insurer is declaring that no “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling processes related to “Date Insurer Paid Bill.”

(9) A Claim administrator 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.

(10) A claim administrator 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 paragraph 69L-7.730(2)(o), F.A.C., who bill on their invoice or letterhead.

(11) A claim administrator or any entity acting on behalf of the insurer, 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:

(a) Maintain the EOBR in a format that can be legibly reproduced; and,

(b) When reporting production data in accordance with the MEIG, as required in subsection 69L-7.740(6), F.A.C., the insurer shall comply with the EOBR instructions contained in subsection 69L-7.740(13), F.A.C.

(12) A claim administrator, sender 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 of 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 subsection 69L-7.740(10), F.A.C.

(13) When a claim administrator 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 subsection 440.13(7), F.S., the insurer shall:

(a) Submit the required data elements to the Division within 45 days of rendering reimbursement; and,

(b) Submit the data as a replacement submission pursuant to the MEIG; and,

(c) Submit the cumulative, not the supplemental, payment information at the line-item level utilizing EOBR code 95 for each line-item reflecting a payment amount differing from the payment amount reported on the original submission; and,

(d) Report the “Date Insurer Received Bill” 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 Bill” as the date the insurer 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.

(14) When a claim administrator or any entity acting on behalf of the insurer has reported medical claims data to the Division that was not required, the claim administrator or any entity acting on behalf of the insurer shall withdraw the previously reported data as described in the MEIG.

(15) When an insurer, claim administrator, or 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 Bill” and “Date Insurer Paid Bill”, submitted by the health care provider and shall not combine multiple bills received from a health care provider into a single medical bill transaction.

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), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New 2-18-16.
Editorial Note: Formerly 69L-7.710(6).