Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule, Forms Incorporated by Reference for Medical Billing, Filing and Reporting, Health Care Provider Medical Billing and Reporting Responsibilities, Insurer Authorization ...

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Worker’s Compensation

RULE NOS.:RULE TITLES:

69L-7.710Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule

69L-7.720Forms Incorporated by Reference for Medical Billing, Filing and Reporting

69L-7.730Health Care Provider Medical Billing and Reporting Responsibilities

69L-7.740Insurer Authorization and Medical Bill Review Responsibilities

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

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 41 No. 91, May 11, 2015 issue of the Florida Administrative Register.

The changes to the proposed rule are being made to address public comments and comments submitted by the Joint Administrative Procedures Committee. Completion instructions for incorporated forms DFS-F5-DWC-9-A, DFS-F5-DWC-9-B, and DFS-F5-DWC-9-C are changed to clarify the dates of use for the ICD-9 and the required use of the ICD-10 upon federal implementation.  The proposed rules also include certain technical changes.

69L-7, F.A.C.:  WORKERS’ COMPENSATION MEDICAL REIMBURSEMENT AND UTILIZATION REVIEW

69L-7.710 Definitions

(1) As used in this Chapter:

(a) through (e) No change.

(f) “Catastrophic Event” means the occurrence of an event outside the control of a claim administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster or an act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent a claim administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and Rule Chapter 69L-7, F.A.C. Programming errors, system malfunctions or electronic data interchange transmission failures that are not a direct result of a catastrophic event are not considered to be a catastrophic event as defined herein. See subsection 69L-7.750(4), F.A.C., for requirements to request approval of an alternative method and timeline for medical report filing with the Division due to a catastrophic event.

(g) through (k) No change.

(l) “Current Dental Terminology” (CDT) means the American Dental Association’s reference document containing descriptive terms to identify codes for billing and reporting dental procedures, as incorporated by reference in  Rule Chapter 69L-8, F.A.C.

(m) “Current Procedural Terminology” (CPT®) means the American Medical Association’s reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services, as incorporated by reference in Rule Chapter 69L-8, F.A.C.

(n) “Date Insurer Paid Bill” and “Date Insurer Paid, Adjusted, Disallowed or Denied” means the date the claim administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. If payment is disallowed or denied, “Date Insurer Paid Bill” and “Date Insurer Paid, Adjusted, Disallowed or Denied” means the date the claim administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits the appropriate notice of disallowance or denial to the health care provider or the health care provider representative. See Rule 69L-7.750(8), F.A.C., for the requirement to accurately report the “Date Insurer Paid Bill.”

(o) “Date Insurer Received Bill” means the date that a Form DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic form equivalent is in the possession of the claim administrator or any entity acting on behalf of the insurer. See Rule 69L-7.750(8), F.A.C., for the requirement to accurately report the “Date Insurer Received Bill.” If a medical bill meets any of the criteria in Rule 69L-7.740(11)(g), F.A.C., and possession of the form is relinquished by the claim administrator or any entity acting on behalf of the insurer by returning the medical bill to the provider with a written explanation for the insurer’s reason for return, then “Date Insurer Received Bill” shall not apply to the medical bill as submitted.

(p) through (t) No change.

(u) “Electronic Filing” means the computer exchange of medical data from a sender to the Division in the standardized format defined in the Florida Medical EDI Implementation Guide (MEIG).

(v) through (z) No change.

(aa) “Florida Medical EDI Implementation Guide (MEIG)” is the Florida Division of Workers’ Compensation’s reference document containing the specific electronic formats, data elements, and requirements for insurer reporting of medical data to the Division, as incorporated by reference in Rule Chapter 69L-8, F.A.C.

(bb) “Healthcare Common Procedure Coding System National Level II Codes (HCPCS)” means the Centers for Medicare and Medicaid Services’ (CMS) reference document listing descriptive codes for billing and reporting professional services, procedures, and supplies provided by health care providers, as incorporated by reference in Rule Chapter 69L-8, F.A.C.

(cc) and (dd) No change.

(ee) “Home Medical Equipment Provider,” sometimes referred to as “durable medical equipment (DME) provider,” is defined in subsection 400.925(7), F.S.

(ff) No change.

(gg) “ICD-9-CM International Classification of Diseases” (ICD-9) is the U.S. Department of Health and Human Services’ reference document listing the official diagnosis and inpatient procedure code sets, as incorporated by reference in Rule Chapter 69L-8, F.A.C.

(hh) “ICD-10 International Classification of Diseases” (ICD-10) is the 10th Edition of the International Classification of Diseases set of diagnosis and inpatient procedure codes, as incorporated by reference in Rule Chapter 69L-8, F.A.C.

(ii) “Implants” means the Surgical Implant(s); the Associated Disposable Instrumentation required for use with the Surgical Implant(s); and shipping and handling, when listed on the implant invoice or certified on the DFS-F5-DWC-90 claim form.

(jj) through (tt) No change.

(uu) “Report” means any form related to medical services rendered, in relation to a workers’ compensation injury that is required to be filed with the Division under Rule Chapter 69L-7, F.A.C.

(vv) through (xx) No change.

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 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06, 3-8-07, 1-12-10, 10-23-12,___-___-___.  Editorial Note: Formerly 69L-7.710(1).

 

69L-7.720 Forms Incorporated by Reference for Medical Billing, Filing and Reporting.

(1) The following forms, including form completion instructions, are incorporated for use with rules adopted under this rule chapter.

(a) Form DFS-F5-DWC-9/CMS-1500 Health Insurance Claim Form, Rev. 02/12; Completion Instructions for Form DFS-F5-DWC-9 are comprised of three sets.

1. through 3. No change.

(b) Form DFS-F5-DWC-10, Statement of Charges for Drugs and Medical Equipment & Supplies Form, Rev. 01/01/2015; Form DFS-F5-DWC-10-A, Completion Instructions for Pharmacies And Home Medical Equipment Providers/Suppliers, Rev. 01/01/2015;

(c) Form DFS-F5-DWC-11, American Dental Association Dental Claim Form, Rev. 2012; Form DFS-F5-DWC-11-A, Completion Instructions for Dentists, Rev. 01/01/2015;

(d) Form DFS-F5-DWC-25, Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form, Rev. 1/31/2008; Form DFS-F5-DWC-25-A, Completion Instructions for Physicians and Recognized Practitioners , Rev 01/01/2015;

(e) Form DFS-F5-DWC-90/UB-04 CMS-1450, Uniform Bill, Rev. 11/03/2006; Completion Instructions for the DFS-F5-DWC-90, are comprised of four sets:

1. Form DFS-F5-DWC-90-A (UB-04), Completion Instructions for Hospitals, Rev. 01/01/2015;

2. Form DFS-F5-DWC-90-B (UB-04), Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (for dates of service on and after 07/08/2010);

3. Form DFS-F5-DWC-90-C (UB-04), Completion Instructions for Home Health Agencies, Rev. 01/01/2015;

4. DFS-F5-DWC-90-D (UB-04), Completion Instructions for Nursing Home Facilities, Rev. 01/01/2015.

(2) Obtaining Copies of Forms and Instructions.

(a) A copy of the Form DFS-F5-DWC-9 can be obtained from the AMA web site at https://commerce.ama-assn.org/store/. Completion instructions for the DFS-F5-DWC-9 can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) website at

http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(b) A copy of the Form DFS-F5-DWC-10 and completion instructions for the form can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(c) A copy of the Form DFS-F5-DWC-11 can be obtained from the American Dental Association web site at http://www.ada.org/. Completion instructions for the form can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(d) A copy of the Form DFS-F5-DWC-25 and completion instructions can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(e) A copy of the instructions for completion of Form DFS-F5-DWC-90, Rev. 11/03/2006; Form DFS-F5-DWC-90-A (UB-04), Completion Instructions for Hospitals, Rev. 01/01/2015; Form DFS-F5-DWC-90-B (UB-04), Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015; Form DFS-F5-DWC-90-C (UB-04), Completion Instructions for Home Health Agencies, Rev. 01/01/2015; Form DFS-F5-DWC-90-D (UB-04), Completion Instructions for Nursing Home Facilities, Rev. 01/01/2015, can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(3) Alternate Billing Form DFS-F5-DWC-10.

In lieu of submitting a Form DFS-F5-DWC-10 when billing for drugs or medical supplies, alternate billing forms are acceptable if:

(a) No change.

(b) The form provides all information required to be submitted to the Division, pursuant to the Florida Medical EDI Implementation Guide (MEIG), on the Form DFS-F5-DWC-10, Form DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form for the DFS-F5-DWC-10.

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, 440.105(7), 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 -   -   -_.  Editorial Note: Formerly 69L-7.710(2). 

 

69L-7.730 Health Care Provider Medical Billing and Reporting Responsibilities.

(1) Bill Submission/Filing and Reporting Requirements.

(a) through (d) No change.

(e) All medical claim form(s) or medical bill(s) related to authorized services shall be coded by the health care provider at the highest level of specificity for the reference material used and submitted to the claim administrator or any entity acting on behalf of the insurer, as a requirement for billing.

(f) Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the claim administrator or any entity acting on behalf of the insurer, provided the insurer agrees.

(g) through (j) No change.

(2) Special Billing Requirements.

(a) When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form shall include the CPT® code and the “P” code (physical status modifier) that correspond with the procedure performed in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code that corresponds with the procedure performed in Field 24D on the next line, if applicable.

(b) When a Certified Registered Nurse Anesthetist (CRNA) provides anesthesia services, the CRNA shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter his/her Florida Department of Health ARNP license number in Field 33b, regardless of the employment arrangement under which the services were rendered, or the identity of the party submitting the bill.

(c) Recognized practitioners, except physician assistants, ARNPs and CRNAs, who are salaried employees of an authorized treating physician and who render direct billable services for which reimbursement is sought from a claim administrator or any entity acting on behalf of the claim administrator, shall report and bill for such services on a Form DFS-F5-DWC-9 under the employing physician’s name and license number.

(d) For hospital billing, the following special requirements apply:

1. Inpatient billing – Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

a. through c. No change.

d. In Form Locator 80 - “Remarks”- make written entry “implant(s)” followed by the certification of the reimbursement amount calculated pursuant to Rule 69L-7.501, F.A.C.

2. Outpatient billing – Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

a. through e. No change.

(e) A certified, licensed physician assistant, or registered nurse first assistant who provides services as a surgical assistant in lieu of a second physician, shall bill on a Form DFS-F5-DWC-9, entering the CPT® code(s) plus modifier(s) representing the service(s) rendered in Field 24D, and shall enter his/her Florida Department of Health license number in Field 33b.

(f) Ambulatory Surgical Centers (ASCs) shall bill as follows:

1. For dates of service up to and including 07/07/2010, ASCs shall bill on Form DFS-F5-DWC-9 using the American Medical Association’s CPT® procedure codes or the workers’ compensation unique procedure code 99070 with required modifiers, and shall bill charges based on the ASC’s Charge Master, except when billing for procedure code 99070.

2. No change.

(g) and (k) No change.

(l) Pharmaceutical(s), Durable Medical Equipment and Home Medical Equipment or Supplies.

1. When dispensing commercially available medicinal drugs commonly known as legend or prescription drugs:

a. No change.

b. Physicians (including oral surgeons), physician assistants, ARNPs, and any other recognized practitioner registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form DFS-F5-DWC-9. Paragraph 440.13(12)(c),F.S,, requires the Original Manufacturer’s NDC Number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-9 Form Completion Instructions  in Rule 69L-7.720, F.A.C.

c. No change.

d. Dentists registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form-DFS-F5-DWC-11. Paragraph 440.13(12)(c), F.S.,  requires the Original Manufacturer’s NDC Number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-11 Form Completion Instructions in Rule 69L-7.720, F.A.C.

2. No change.

3. When dispensing over-the-counter drug products:

a. No change.

b. Physicians (including oral surgeons), physician assistants and ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the 11 digit NDC number in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. No change.

4. When administering or dispensing injectable drugs:

a. No change.

b. Physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field 24D. When an appropriate HCPCS “J” code is not available for the injectable drug, enter the 11 digit NDC number, preceded by the alpha-numeric qualifier (N4), in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. No change.

5. through 8. No change.

(m) through (p) No change.

(3) Bill Completion.

(a) No change.

(b) Billing elements required by the Division to be completed by a health care provider are identified in Form DFS-F5-DWC-9 completion instructions (Rev. 01/01/2015) available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-9-A Instructions Rev. 01/01/15, when submitted by Physicians and Recognized Practitioners;

2. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-9-B Instructions Rev. 01/01/15, when submitted by Work Hardening and Pain Management Programs; 

3. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-9-C Instructions Rev. 01/01/15, when submitted by an ASC for dates of services before 07/08/2010.

(c) Billing elements required by the Division to be completed for Pharmaceutical or Medical Supplier Billing are identified in Form DFS-F5-DWC-10-A Completion Instructions, Rev.1/01/2015, available at website: http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-10-A Instructions Rev. 01/01/15. 

(d) Billing elements required by the Division to be completed for Dental Billing are identified in Form DFS-F5-DWC-11-A Completion Instructions, Rev.01/01/2015, available at website: http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-11-A Instructions Rev. 01/01/15. 

(e) Billing elements required by the Division to be completed by Facilities are identified in the Form DFS-F5-DWC-90 (UB-04) Completion Instructions, Rev. 01/01/15, available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-90-A Instructions Rev. 01/01/15, when submitted by a Hospital.

2. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-90-B Instructions Rev. 01/01/15, when submitted by an Ambulatory Surgical Center for dates of services on or after 7/8/2010. 

3. http://www.myfloridacfo.com/Division/WC/provider/Form DFS-F5-DWC-90-C Instructions Rev. 01/01/15, when submitted by a  Home Health Agency.

4. http://www.myfloridacfo.com/Division/WC/provider/ Form DFS-F5-DWC-90-D Instructions Rev. 01/01/15, when submitted by a Nursing Home Facility.

(f)  No change.

(g) A health care provider may bill consistent with the requirements of ICD-10 beginning on the implementation date specified for use of ICD-10 in Section 162.1002 of Title 45 of the Code of Federal Regulations. Under no circumstance may a health care provider utilize both ICD-9 and ICD-10 coding on the same bill.

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 ___-___-___.  Editorial Note: Formerly 69L-7.710(4). 

 

69L-7.740 Insurer Authorization and Medical Bill Review Responsibilities.

(1) through (6) No change.

(7) When an injured employee does not have a Social Security Number or a previously assigned Division-Assigned Number, the claim administrator or entity acting on behalf of the insurer shall contact the Division via email at [e-mail] to obtain a Division-Assigned Number prior to submitting the medical report to the Division.

(8) and (9) No change.

(10) When utilizing the option(s) available under Rule 69L-7.750(8)(a), F.A.C., the insurer shall document the following:

(a) through (b) No change.

       (c) The insurer shall make this written documentation available to the Division for audit purposes pursuant to  Section 440.525, F.S.  The insurer shall maintain written documentation from the “entity” acknowledging its responsibilities concerning “Date Insurer Received Bill” and “Date Insurer Paid Bill” for each option when the insurer selects options 2., 3., or 4. from Rule 69L-7.750(8)(a), F.A.C., and shall also maintain written documentation identifying the applicability of the options selected in sufficient detail to allow verification of the coding of each medical bill under Rule 69L-7.750(8)(c), F.A.C.

(11) and (12) No change.

(13) In completing an Explanation of Bill Review (EOBR), a claim administrator shall, for each line item billed, select the EOBR code(s) from the list below which identifies(y) the reason(s) for the reimbursement decision for each line item.

(a) No change.

(b) The EOBR code list is as follows:

06 No change.

10 and 11 No change.

21 through 24 – No change. 

25 Payment disallowed: medical necessity: service rendered was experimental, investigative or research in nature (insurer shall provide supporting documentation).

26 through 41 – No change.

42 No change.

43 through 49 – No change.

50 Payment disallowed: insufficient documentation: specific documentation requested in writing at the time of authorization not submitted with the medical bill (insurers shall specify omitted documentation).

51 through 61 – No change.

62 Payment disallowed: billing error: incorrect procedure, modifier, units, supply code. (insurer shall identify incorrect code).

63 through 75 No change.

80 Payment adjusted: billing error: correction of procedure, modifier, supply code, units, or Original Manufacturer’s NDC Number (shall identify correction).

NOTE:  Shall not be used with repackaged medications.

81 through 84 – No change.

85 Payment adjusted: no modification to the information provided on the medical bill. Payment made pursuant to a letter of agreement between the health care provider and the carrier for a specific date of service or procedure.

NOTE:  EOBR Code 85 shall not be used in lieu of EOBR Code 93.

86 Payment adjusted: billing error; repackaged medication; correction of NDC number dispensed or reimbursed pursuant to paragraph 440.13(12)(c), F.S. (insurer shall indicate the corrected  NDC number dispensed or reimbursed).

90 through 92 No change.

93 Paid: no modification to the information provided on the medical bill: payment made pursuant to written contractual arrangement (network or PPO name required).

NOTE: EOBR Code 93 shall not be used in lieu of EOBR Code 85.

94 Paid: Out-of-State Provider: payment made pursuant to the Out-of-State Provider section of the applicable Florida reimbursement manual.

95. Paid: Reimbursement Dispute Resolution: payment made pursuant to receipt of a Determination or Final order on a Petition for Resolution of Reimbursement Dispute, pursuant to subsection 440.13(7), F.S.

96. through 98 – No change.

(14) and (15) No change.

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 ___-___-___.  Editorial Note: Formerly 69L-7.710(5). 

 

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

(1) through (7) No change.

(8)(a) and (b) No change.

(c) The option in Rule 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 Rule 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 Rule 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 Rule 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 Rule 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling processes related to “Date Insurer Paid Bill.”

(9) and (10) No change.

(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) No change.

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

(12) No change.

(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) through (d) No change.

(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) No change.

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 ___-___-___.  Editorial Note: Formerly 69L-7.710(6). 

 

The remainder of the remainder of the rule reads as previously published.