Definitions, Petition Form, Carrier Response Form, Petition Requirements, Service of Petition on Carrier and Affected Parties, Petition Withdrawal
DEPARTMENT OF FINANCIAL SERVICES
Division of Workers' Compensation
RULE NOS.:RULE TITLES:
69L-31.002Definitions
69L-31.003Petition Form
69L-31.004Carrier Response Form
69L-31.005Petition Requirements
69L-31.007Service of Petition on Carrier and Affected Parties
69L-31.013Petition Withdrawal
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. 45 No. 228, November 22, 2019 issue of the Florida Administrative Register.
69L-31.002 Definitions.
The definitions that follow and those in section 440.13(1), F.S., apply to capitalized terms used in this rule chapter:
(1) “Notice of Disallowance or Adjustment” means an a document that identifies the amount of disallowance or adjustment of payment that corresponds with the medical bill submitted by the Health Care Provider; Explanation of Bill Review (EOBR) as defined by paragraph 69L-7.710(1)(y), F.A.C.
(2) through (4) No change.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New_____.
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 revised MM/YYYY, 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-_____ or by contacting the Department at (850)413-1613.
(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. Instructions for submission of the Petition Form are included on the bottom 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) through (c) No change.
(d) If the services provided in the Notice of Disallowance or Adjustment were alleged by the Carrier as being reimbursed provided pursuant to a contract:, documentation substantiating the contract was in effect for the line item(s) in dispute and the provision which governs reimbursement for the services;
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, either 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, or supporting medical notes and records for the line item(s) in dispute; any relevant section(s) of evidence-based practice guidelines the Petitioner relied upon to support the Medical Necessity of the services in the contested line item(s) (in the absence of, or deviation from, the evidence-based practice guidelines, the Petitioner may provide a signed document from 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);
(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) No change.
(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), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.003, Amended ___.
Form DFS-F6-DWC-3160-0023 was amended as follows: Some font sizes increased. Grammatical corrections made. Changed “Revised” to “Effective” in the footer. Edited content of third box on form to remove “please.” Added “or if no such entity was designated by the Carrier, upon the entity that sent the notice” to the end of #2. Amended requests for documents below the question in #4 to read:
If “Yes,” and Petitioner is disputing that payment is being made at an amount less than the amount prescribed in such contract, provide the documentation substantiating the contract was in effect for the line item(s) in dispute and provide the provision which governs reimbursement for service(s).
If “Yes,” and Petitioner is disputing the applicability of the contract to the line item(s) in dispute, 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 “No,” but the services in the Notice of Disallowance or Adjustment were alleged by Carrier as being provided pursuant to a contract and there had been a contract that was no longer in effect for the line item(s) in dispute, provide documentation substantiating that there was no contract in effect for the line item(s) in dispute.
Removed “please” from #5. Amended requests below the question in #6 to read:
If “No,” was the Providers treatment “Emergency Care”? Yes ___ No ___
If authorization was obtained, provide a copy of the authorization.
Added the following language above the signature line: “Section 837.06, F.S., False official statements. – Whoever knowlingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.”
69L-31.004 Carrier Response to Petition for Resolution of Reimbursement Dispute Form and Requirements.
(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0024, effective revised MM/YYYY, 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-_____ or by contacting the Department at (850)413-1613.
(2) No change.
(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 440.13(7)(b), F.S.
(a) If the 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. EOBR code 10 or 11 (used to deny payment because the service rendered is for a non-compensable injury or illness) was used as a reason to deny payment for the line item(s) the Petitioner contends was improperly denied, a copy of the Form DFS-F2-DWC-12, Notice of Denial, adopted in Rule 69L-3.025, F.A.C., that was sent to the injured worker and Health Care Provider pursuant to Rule 69L-56.4012, F.AC., must be included as part of the supporting documentation.
(b) If the Carrier disallowed 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. relied upon evidence-based practice guidelines to support the disallowance of payment for the Medical Necessity of services in the Notice of Disallowance or Adjustment, the Carrier may submit the relevant section(s) of the evidence-based practice guidelines, along with a signed document from the Carrier’s medical director confirming that the relevant section(s) of the evidence-based practice guidelines is the reason for the disallowance or adjustment of payment. Absent any relevant section(s) of evidence-based practice guidelines, the Carrier may provide a Peer Review to support the disallowance of payment for the Medical Necessity of services in the contested line item(s) in the Notice of Disallowance or Adjustment.
(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 paragraphs (3)(d) or (3)(i) of section 440.13, F.S., if any.
(4) No change.
(5) Any submission by a Carrier pursuant to section 440.13(7)(b), F.S., that 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.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.004, Amended ____.
Form DFS-F6-DWC-3160-0024 was amended as follows: Some font sizes increased. Grammatical corrections made. Changed “Revised” to “Effective” in the footer. Edited content of third box on form to remove “please.” Corrected typo in form number in footer. Changed “If yes” to “If ‘Yes’” in request #4. Removed the word “please” in request #5. Amended request #6 to read:
Was the Petitioner authorized to treat the injured worker for the date(s) of service in dispute? Yes ___ No ___
If “No,” did the Petitioner submit a request of authorization? Yes ___ No ___
If authorization was requested, provide a copy of the Petitioner’s authorization request and a copy of the carrier’s response.
Added the following language above the signature line: “Section 837.06, F.S., False official statements. – Whoever knowlingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.”
69L-31.005 Written Determinations.
(1) The Department will render a written determination on whether the Carrier properly adjusted or disallowed payment pursuant to section 440.13(7)(c), F.S., by relying on by relying upon the applicable reimbursement schedules, practice parameters, protocols of treatment, and standards and policies set forth in chapter 440, F.S. (and the rules promulgated therefrom), along with the Petition Form, Response Form, and all supporting documentation submitted to the Department by the Petitioner and the Carrier to support their respective positions. The Department will use an Expert Medical Advisor (EMA), in accordance with section 440.13(9)(b), F.S., to assist in resolving resolve Reimbursement Disputes associated with the disallowance or adjustment of payment based upon: 1) overutilization; or 2) Medical Necessity of the services in the Notice of Disallowance or Adjustment when both the Petitioner (pursuant to paragraph 69L-31.003(3)(e), F.A.C.) and Carrier (pursuant to paragraph 69L-31.004(3)(b), F.A.C.) have provided documentation to support their respective decisions on the Medical Necessity of the services. If an EMA is utilized by the Department, all forms and documentation received pursuant to Rules 69L-31.003 and 69L-31.004, F.A.C., will be forwarded to the EMA.
(2) In its written determination, the Department will only address the specific line item(s) in the Notice of Disallowance or Adjustment that the Petitioner contends were improperly disallowed or adjusted.
(3) Failure by If the Carrier has failed to issue an Explanation of Bill Review (EOBR) that meets meet the requirements requirement set forth in paragraph 69L-31.004(3)(a) of subsection 69L-7.740(14), F.A.C., may result in a determination in favor of the Petitioner, along with one or more of the following penalties in sections 440.13(7)(f) and 440.525, F.S., and Rule 69L-24.007, F.A.C. the Department, in its written determination, will only address the specific line item(s) in the Notice of Disallowance or Adjustment that the Petitioner contends were improperly denied.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(9), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.005, Amended ___.
69L-31.007 Service of Petition on Carrier and All Affected Parties.
(1) The Petitioner must effectuate service on the Carrier and on all affected parties by serving a copy of the Petition Form, and all supporting documentation submitted to the Department, by United States Postal Services (USPS) certified mail on the specific entity identified on the Notice of Disallowance or Adjustment as the entity the Carrier designates to receive service of the Petition Form and all supporting documentation on behalf of the Carrier and all affected parties. If the Notice of Disallowance or Adjustment does not specifically identify the name and mailing address of the entity the Carrier designates to receive service on behalf of the Carrier and all affected parties, as required by subsection 69L-7.740(14), F.A.C., the Petitioner may effectuate service of the Petition Form upon the Carrier and all affected parties by serving a copy of the Petition Form and copies of all documents and records in support of the Petition Form by United States Postal Service (USPS) certified mail upon the entity who issued the Notice of Disallowance or Adjustment. Service by delivery other than USPS certified mail or service by common carrier does not constitute service by USPS certified mail, as required by section 440.13(7)(a), F.S., even if the Carrier’s delivery and receipt of the documents is petition are confirmed. Service by USPS delivery other than USPS certified mail or service by common carrier does not constitute service by USPS certified mail, as required by section 440.13(7)(a), F.S., even if the Carrier’s receipt of the documents is confirmed.
(2) If a Carrier has not been properly served in accordance with this rule, the Petitioner will be notified by the Department of the deficiency in service. The Petitioner will have twenty (20) ten (10) calendar days from receipt of the notice of deficiency in service to provide the Department with proof the deficiency in service identified in the notice of deficiency has been cured by proper service. If the Department does not receive proof of proper service within have twenty (20) ten (10) calendar days after Petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice. For purposes of this rule, “proof of proper service” means that a copy of the Petition Form, and one copy set of all documents and records in support of the petition have been delivered all supporting documentation submitted to the Department, have been sent by USPS certified mail to the proper entity at the proper address as set forth in this rule and a certified mail receipt number is provided to the Department to confirm service. mailing.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.007, Amended ___.
69L-31.013 Petition Withdrawal.
(1) Prior to the issuance of a determination, Tthe Petitioner may voluntarily withdraw its Petition Form prior to the conclusion of a final hearing or the issuance of a final order, whichever occurs first, or participate in an informal disposition under section 120.57(4), F.S.
(2) through (3) No change.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.013, Amended ____.
