The proposed rulemaking amends existing rules governing the process for the resolution of reimbursement disputes between workers’ compensation carriers and health care providers, creates two new rules, and repeals an existing rule. Noteworthy ...

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Worker's Compensation

RULE NOS.:RULE TITLES:

69L-31.003Petition Form

69L-31.004Carrier Response Form

69L-31.005Petition Requirements

69L-31.006Consolidation of Petitions

69L-31.007Service of Petition on Carrier and Affected Parties

69L-31.008Computation of Time

69L-31.009Carrier Response Requirements

69L-31.010Effect of Non-Response by Carrier

69L-31.011Complete Record

69L-31.012Joint Stipulation of the Parties

69L-31.013Petition Withdrawal

69L-31.014Overutilization Issues Raised in Reimbursement Dispute Resolution

69L-31.016Reimbursement Disputes Involving a Contract or Workers' Compensation Managed Care Arrangement

69L-31.017Carrier and Health Care Provider Non-compliance

PURPOSE AND EFFECT: The proposed rulemaking amends existing rules governing the process for the resolution of reimbursement disputes between workers’ compensation carriers and health care providers, creates two new rules, and repeals an existing rule. Noteworthy highlights of the proposed rulemaking are as follows: Rule 69L-31.005, F.A.C., is amended to provide greater detail regarding the materials that must accompany a petition for dispute resolution; Rule 69L-31.008, F.A.C., is amended to clarify the computation of the time period within which a petition for dispute resolution must be submitted to the Division, to increase the time period from 30 days to 45 days for the submission of a Petition Form, to add a link to the Division’s Web Portal, and to provide additional guidance regarding the electronic submission of a Petition Form; Rule 69L-31.009, F.A.C., is amended to increase the time period for a carrier to respond to a petition from 10 days to 30 days; Rule 69L-31.012, F.A.C., is repealed; proposed new Rule 69L-31.016, F.A.C., specifies that the scope of Department determinations involving reimbursement disputes is limited to findings relating to reimbursement schedules, practice parameters, and protocols of treatment, and clarifies that the Department will issue no findings regarding an improper disallowance or adjustment in reimbursement involving managed care contracts or when the carrier asserts that medical treatment was either not compensable or not medically necessary; and proposed new Rule 69L-31.017, F.A.C., stipulates the consequences for failure to comply with Department determinations. Certain rule section titles are revised to more accurately reflect the subject matter or issues addressed by the underlying rule. The proposed rules include additional minor edits and technical changes, and have been renumbered accordingly. Revised forms are also adopted.

SUMMARY: : Rulemaking to amend rules governing the procedures for the resolution of reimbursement disputes between workers’ compensation carriers and health care providers, identified under Rule Chapter 69L-31, F.A.C.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: Preliminary SERC analyses conducted by the Department indicate that none of the proposed rules will have an adverse impact or result in regulatory costs in excess of $1 million within five years, as established in paragraph 120.541(2)(a), F.S.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 440.13(7)(e), 440.591, FS.

LAW IMPLEMENTED: 440.13(7) (a), (b), (c), (e), FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW (IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):

DATE AND TIME: Thursday, January 5, 2017, 1:00 p.m.-3:00 p.m.

PLACE: Room 102, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida.

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Theresa Pugh, telephone: [phone], email: [e-mail].. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Theresa Pugh, Program Administrator, Medical Services Section, Bureau of Monitoring and Audit, Division of Workers’ Compensation, Department of Financial Services, address: 200 East Gaines Street, Tallahassee, Florida 32399-4228, telephone: [phone], email: [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

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

(1) The Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC 3160-0023, Revised ______ (“Petition Form”), (DFS Form 3160-0023, effective September 8, 2006) is hereby incorporated by reference in this rule chapter. This form may be obtained on the Department’s website Internet at http://www.myfloridacfo.com/Division/WC/pdf/DFS-3160-0023.pdf http://www.myfloridacfo.com/wc/forms.html or by contacting the Department at [phone].

(2) All references to a “petitioner” in this rule chapter are to the health care provider or entity acting on behalf of the health care provider submitting a Petition Form to contest carrier disallowance or adjustment of payment.

(3)(2) A petition to contest carrier disallowance or adjustment of payment pursuant to paragraph Section 440.13(7)(a), F.S., must be submitted on the Petition for Resolution of Reimbursement Dispute Form in hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/.   The Petition Form will be the only form accepted by the Department. Any submission seeking to contest the disallowance or adjustment of payment by a carrier pursuant to Section 440.13(7)(a), F.S., must include a completed Petition for Resolution of Reimbursement Dispute Form.

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

 

69L-31.004 Carrier Response to Petition for Resolution of Reimbursement Dispute Form.

(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC 3160-0024, Revised _______ (Response Form), (DFS Form 3160-0024, effective September 8, 2006) is hereby incorporated by reference in this rule chapter. This form may be obtained on the Department’s website Internet at http://www.myfloridacfo.com/Division/WC/pdf/DFS-3160-0024.pdf http://www.myfloridacfo.com/wc/forms.html or by contacting the Department at [phone].

(2) All references to a “carrier” in this rule chapter include the carrier or any entity acting on the carrier’s behalf in administering the carrier’s workers’ compensation medical claims.

(3)(2) The Response Form will be the only form accepted by the Department upon which a carrier may submit its response to a Petition Form to contest carrier disallowance or adjustment of payment pursuant to The Carrier Response to Petition for Resolution of Reimbursement Dispute Form shall be considered a required element of the requested documentation to the Department under paragraph Section 440.13(7)(b), F.S. and must be submitted in hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/. Information contained in the Explanation of Bill Review (EOBR) or notice of disallowance or adjustment of payment will control for purposes of establishing the carrier’s basis for disallowance or adjustment of payment. The Carrier Response to Petition for Resolution of Reimbursement Dispute Form shall be the only form accepted by the Department upon which a carrier may submit to the Department its response to a Petition for Resolution of Reimbursement Dispute. Any submission by a carrier pursuant to Section 440.13(7)(b), F.S., that does not include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute Form shall result in a notice of deficiency by the Department. A carrier shall have ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency identified in the Department’s notice of deficiency. Failure to timely cure the deficiency shall constitute failure to submit requested documentation to the Department.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New 11-28-06, Formerly 59A-31.004, Amended__________.

 

69L-31.005 Petition Form Requirements and Reasons for Dismissal.

(1) The Department, in its determination, will address only the specific line item(s) in the Explanation of Bill Review (“EOBR”) or notice of disallowance or adjustment of payment that the health care provider contends were improperly disallowed or adjusted.

(2)(1) The petitioner must submit the Petition Form and all documentation All documents and records that support supporting the allegations contained in the Petition Form petition must accompany the petition. The supporting documentation of the items listed below must be submitted by hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/. A petition that is accompanied by all items specified below will not be dismissed for failure to submit supporting documents and records:

(a) A copy of each EOBR or notice of disallowance or adjustment of payment Explanation of Bill Review received from the carrier providing notice of disallowance or adjustment of payment in this dispute.

(b) A copy of all the medical bill or medical bills or request(s) for reimbursement sent to the carrier for which payment was disallowed or adjusted by the carrier on each the contested EOBR or notice of disallowance or adjustment of payment Explanation of Bill Review(s).

(c) One copy set of all related medical documentation and records submitted to the carrier in support of the medical service(s), bill(s) or request(s) for reimbursement which are the subject of this dispute.

(d) If the answer to question 5 on the Petition for Resolution of Reimbursement Dispute Form is yes, a copy of all applicable provision(s) of the reimbursement contract.

(d)(e) If the reimbursement dispute involves carrier authorization of non-emergency treatment, a copy of the provider’s Provider’s documentation of prior authorization by the carrier for non-emergency treatment for the date(s) of service addressed on the Petition Form covered by the petition.

(e)(f) If the reimbursement dispute involves carrier notification of emergency treatment, a copy of the documentation Documentation of health care provider notification to the carrier, pursuant to paragraph Section 440.13(3)(b), F.S., for emergency treatment or admission following emergency treatment for the date(s) of service addressed on the Petition Form included in the petition.

(f) If the reimbursement dispute involves repackaged medication, a copy of the Prescription (Legend) Drug Pedigree documenting the ownership and distribution history of that medication.

(g) If the reimbursement dispute involves services provided by a hospital, documentation of the portions of the hospital’s charge master pertinent to the billed services as of the date of service.

(h) If the reimbursement dispute involves Surgical Implants, a copy of the acquisition invoice(s) from the health care facility for Surgical Implants and Associated Disposable Instrumentation billed, and the record or implant log reflecting the utilization of items.

(3) The Petition Form will be dismissed if:

(a) The Petition Form is submitted to the Department more than forty-five (45) calendar days from the health care provider’s receipt of the EOBR or notice of disallowance or adjustment of payment from the carrier; or

(b) The Petition Form is a duplicate of a previously submitted Petition Form with all of the same issues for the same injured employee, health care provider, carrier, and date(s) of service;

(c) The claim is subject to another jurisdiction; or

(d) The carrier is compliant with Rule 69L-56.4012, F.A.C.

(4)(2) If the petitioner does not submit a completed Petition for Resolution of Reimbursement Dispute Form, accompanied by all of the items specified in subsection 69L-31.005(2)(1), F.A.C., the petitioner will be notified by the Department of the deficiency in submission. The petitioner shall will have ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Department copies of the items specified in the Department’s notice along with proof of proper service of the curative documentation upon the carrier by hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/. If the petitioner Department does not submit receive the curative documentation to the Department and provide proof of service of the curative documentation upon the carrier within ten (10) calendar days after petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice.

(3) Documents and records accompanying the petition must be submitted in hard copy.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New 11-28-06, Formerly 59A-31.005, Amended________.

 

69L-31.006 Consolidation of Petitions.

(1) If multiple Petition Forms petitions addressing the same substantive issue(s) have been filed by a petitioner contesting disallowance or adjustment of payment by the same carrier for the same injured employee, the Department may, in its discretion, consolidate the Petition Forms petitions into a single determination.

(2) If the Department consolidates multiple petitions into a single determination, the timetable for rendering a determination upon a consolidated petition shall be expanded to 120 days after Department receipt of all documentation.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(e) FS. History–New 11-28-06, Formerly 59A-31.006, Amended_________.

 

69L-31.007 Service of Petition on Carrier and Affected Parties.

(1) The petitioner must shall effectuate service on upon the carrier and on all affected parties by serving a copy of the Petition Form petition and all supporting documentation submitted to the Department documents and records in support of the petition, by United States Postal Service (henceforth referred to as “USPS” throughout this rule chapter) certified mail on the specific entity identified on the Explanation of Bill Review (“EOBR”) or notice of disallowance or adjustment of payment as the entity the carrier designates to receive service of the Petition Form and copies of all supporting documentation on behalf of the carrier and all affected parties. If the EOBR or notice of disallowance or adjustment of payment Explanation of Bill Review does not specify a specifically identify the name and mailing address for 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) paragraph 69L-7.602(5)(q), F.A.C., the petitioner may effectuate service of the Petition Form on petition upon the carrier and all affected parties by serving a copy of the Petition Form petition and copies of all supporting documentation documents and records in support of the Petition Form petition by United States Postal Service (USPS) certified mail on upon the entity that who issued the EOBR or notice of disallowance or adjustment of payment Explanation of Bill Review at the address from which the EOBR or notice of disallowance or adjustment of payment Explanation of Bill Review was issued.

(2) The A Petition Form for Resolution of Reimbursement Dispute must be served on upon the carrier and all affected parties by United States Postal Service (USPS) certified mail. Service on upon the carrier must shall include one copy set of all documents and records documentation submitted to the Department in support of the Petition Form petition.

(3) Service by certified mail means service by United States Postal Service (USPS) certified mail. Service by common carrier or service by United States Postal Service (USPS) delivery other than USPS certified mail or service by common carrier does not constitute service by USPS certified mail, as required by paragraph 440.13(7)(a), F.S. statute, even if carrier delivery and receipt of the Petition Form petition are confirmed.

(4) If a carrier or the entity the carrier designates to receive service has not been properly served in accordance with this rule subsection, the petitioner will be notified by the Department of the deficiency in service. The petitioner will shall have 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 petitioner Department does not submit receive proof of proper service to the Department within 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 petition and one copy set of all documentation documents and records in support of the Petition Form petition have been sent by United States Postal Service (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. If the petitioner unsuccessfully attempts to effectuate service on the carrier, its designated entity, or the entity issuing the EOBR or notice of disallowance or adjustment of payment at the service address as it is listed on the EOBR or notice of disallowance or adjustment of payment because the service address as listed is incorrect or invalid, the Petition Form will not be dismissed. 

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a) FS. History–New 11-28-06, Formerly 59A-31.007, Amended_________.

 

69L-31.008 Computation of Time.

(1)(a) An Explanation of Bill Review (“EOBR”) that meets the requirements of paragraph 69L-7.740(14), F.A.C., constitutes a notice of disallowance or adjustment of payment for the purposes of calculating the forty-five (45) day time period in subsection 440.13(7), F.S.

(b) In addition, any document issued by or on behalf of the carrier that includes the following information constitutes a notice of disallowance or adjustment of payment for the purposes of calculating the forty-five (45) day time period in subsection 440.13(7), F.S.

1. The document must identify the amount of disallowance or adjustment of payment that corresponds with the medical bill submitted by the health care provider.

2. The document must identify the name and address of the carrier and the entity issuing the notice of disallowance or adjustment of payment.

3. The document must contain a statement indicating that the document is issued for purposes of noticing the health care provider of the disallowance or adjustment of payment for purposes of subsection 440.13(7), F.S.

4. The document must identify specific EOBR codes related to the adjudication of each line item billed pursuant to Rule 69L-7.740, F.A.C.

(c) The forty-five (45) day time period within which a Petition Form must be served on the Department begins upon receipt of the EOBR or notice of disallowance or adjustment of payment by the health care provider or by an entity designated by the provider to receive such notice on behalf of the health care provider.

(d) The health care provider must document receipt of the EOBR or notice of disallowance or adjustment of payment using a date stamp that clearly reflects date of receipt of the EOBR or notice of disallowance or adjustment of payment by the health care provider or by using a verifiable login process. Documentation of receipt through a date stamp or verifiable login process must accompany the Petition Form. A date-stamped EOBR or notice of disallowance or adjustment of payment will be accepted as proof of date of receipt. A copy of the applicable portion of the login roster showing the date of login of the EOBR or notice of disallowance or adjustment of payment will be accepted as proof of date of receipt through a verifiable login process.

(1) Pursuant to paragraph 69L-7.602(5)(q), F.A.C., notice of disallowance or adjustment of payment, which begins the thirty (30) day time period in Section 440.13(7), F.S., shall only be through receipt of an Explanation of Bill Review issued by or on behalf of a carrier. Therefore, the thirty (30) day time period within which a petition must be served upon the Department begins upon receipt of the Explanation of Bill Review by the health care provider or by an entity designated by the provider to receive such notice on behalf of the health care provider. The health care provider shall document receipt of the Explanation of Bill Review using a date stamp, which clearly reflects date of receipt, or by using a verifiable login process. Documentation of receipt through a date stamp or verifiable login process shall accompany the petition. A date stamped Explanation of Bill Review will be accepted as proof of date of receipt by date stamp. A copy of the applicable portion of the login roster showing the date of login of the Explanation of Bill Review will be accepted as proof of receipt through a verifiable login process. If receipt cannot be established through a date stamp or verifiable login process, the health care provider may provide with the petition a copy of the envelope in which the Explanation of Bill Review was sent which clearly and legibly shows the postmark date, in which case receipt will be deemed to be five (5) calendar days from the postmark date on the envelope in which the Explanation of Bill Review was sent. If the health care provider does not establish the date of its receipt of the Explanation of Bill Review by any of the methods set forth in this subsection through documentation accompanying the Petition, the health care provider receipt of the Explanation of Bill Review will be deemed to be five (5) calendar days from the issue date on the Explanation of Bill Review. An affidavit attesting to date of receipt will not be accepted as proof of date of receipt.

(2) Petitioning the Department to resolve a reimbursement dispute is shall be effectuated upon service of the Petition Form on petition upon the Department. The timeliness of a Petition Form will petition for Resolution of Reimbursement Dispute shall be calculated based upon on service of the Petition Form on petition upon the Department. Service on upon the Department must shall be by United States Postal Service (USPS) mail, by common carrier, or by hand delivery, or by electronic submission via the Division of Workers’ Compensation Web Portal. If service is by United States Postal Service (USPS) mail, the date of service on the Department will shall be the postmark date placed on the envelope by USPS or the metered mail date. If service is by common carrier, the date of service on the Department will shall be the common carrier pick-up date. If service on the Department is by hand delivery, the date of service is the date the Petition Form petition is hand delivered to: Receptionist, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida. Service on the Department by hand delivery is available Monday through Friday between 8:00 a.m. and 5:00 p.m., (Eastern Time), excluding state holidays. If service is by electronic submission via the Division of Workers’ Compensation Web Portal, the date of service will be the date the Department received the electronic documentation.

(3) Carrier date of receipt of the Petition Form petition by USPS certified mail will be established by reference to the United States Postal Service (USPS) certified mail receipt date. Timely submission by the carrier to the Department of the Carrier Response to Petition for Resolution of Reimbursement Dispute Form and supporting accompanying documentation will to the Department shall be determined based on upon the date of service of the Carrier Response to Petition for Resolution of Reimbursement Dispute Form and supporting accompanying documentation to on the Department. If service on the Department is by United States Postal Service (USPS) mail, the date of service shall will be the postmark date placed on the envelope by USPS or the metered mail date. If service on the Department is by common carrier, the date of service will shall be the common carrier pick-up date. If service on the Department is by hand delivery, the date of service is the date the Response Form petition is hand delivered to: Receptionist, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida. Service by hand delivery is available Monday through Friday between 8:00 a.m. and 5:00 p.m., (Eastern Time), excluding state holidays. If service is by electronic submission via the Division of Workers’ Compensation Web Portal, the date of service will be the date the Department received the electronic documentation.

(4) Time periods established for petitioning the Department to resolve a reimbursement dispute or responding to a Petition Form are not tolled by any of the following actions: requesting an on-site audit; conducting an on-site audit; referral of the health care provider for peer review consultation; or an independent medical examination of the injured employee. Neither the request for, nor the conducting of, an on-site audit, nor the referral of the health care provider for peer review consultation, nor independent medical examination shall toll the time period for petitioning the Department for the resolution of a reimbursement dispute as set forth in Section 440.13(7)(a), F.S., or the time period for the carrier to submit requested documentation under Section 440.13(7)(b), F.S.

(5) If a health care provider submits a Petition Form with multiple notices of disallowance or adjustment of payment or EOBRs for the same claimant, date(s) of service and services, the Department will determine timeliness of the Petition Form from the latest notice of disallowance or adjustment of payment or EOBR that adjusts payment.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a), (b) FS. History–New 11-28-06, Formerly 59A-31.008, Amended________.

 

69L-31.009 Carrier Response Requirements.

(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form, accompanied by all supporting documentation in hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/ requested information, must be served on upon the Department no later than thirty (30) calendar within ten (10) days after the carrier’s receipt of a copy of the Petition Form petition by United States Postal Service (USPS) certified mail. However, where the Carrier has received curative documentation from the Petitioner pursuant to subsection 69L-31.005(2), F.A.C., the Carrier Response to Petition for Resolution of Reimbursement Dispute Form, accompanied by all requested information, must be served upon the Department within ten (10) calendar days after receipt, by the carrier of the curative documentation from the Petitioner. The carrier’s response to the Petition Form petition must include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute Form (DFS Form 3160-0024, effective September 8, 2006). Failure of the carrier to meet these requirements constitutes waiver of all objections to the petition.

(2) The carrier must shall provide to the petitioner, using a delivery method providing which provides confirmation of date of delivery, at the petitioner’s mailing address provided on the Petition for Resolution of Reimbursement Dispute Form, a copy of the carrier Response to Petition for Resolution of Reimbursement Dispute Form, and one copy set of all supporting documentation accompanying information served on upon the Department in response to the Petition Form petition. The carrier must document the delivery tracking information on the Response Form in such detail that the Department can verify the health care provider’s receipt of the Response Form and supporting documentation.

(3) Any submission by a carrier pursuant to paragraph 440.13(7)(b), F.S., that does not include a completed Response Form will result in a notice of deficiency by the Department. A carrier will have ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Department copies of the items identified in the notice by hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/. Failure of the carrier to meet these requirements constitutes waiver of all objections to the Petition Form. Documents and records accompanying the carrier’s Response to Petition for Resolution of Reimbursement Dispute Form must be in hard copy.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New 11-28-06, Formerly 59A-31.009, Amended________.

 

69L-31.010 Effect of Non-Response by Carrier.

Failure by of the carrier to timely submit a Carrier Response to Petition for Resolution of Reimbursement Dispute Form (DFS Form 3160-0024, effective September 8, 2006) and supporting accompanying documentation substantiating its disallowance or adjustment of payment constitutes a waiver of all objections to the Petition Form, pursuant to paragraph 440.13(7)(b), F.S petition. Waiver of all objections to the Petition Form will petition shall result in the Department determination and applicable final order being based solely upon the allegations and supporting documentation submitted by the petitioner.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New 11-28-06, Formerly 59A-31.010, Amended________.

 

69L-31.011 Complete Record.

The evidentiary record upon which the Department’s determination will be made will consist of shall be the Petition for Resolution of Reimbursement Dispute Form and all documentation supporting the allegations contained therein, the documents and records accompanying the petition and the Carrier’s Response to Petition for Resolution of Reimbursement Dispute Form and all supporting accompanying documents. However, if the petitioner and carrier enter into a joint stipulation of the parties pursuant to Rule 69L-31.012, F.A.C., the evidentiary record upon which the Department’s determination will be made shall also include all additional supporting documentation submitted to the Department by the parties within the 10 calendar day period provided for in Rule 69L-31.012, F.A.C.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(c) FS. History–New 11-28-06, Formerly 59A-31.011, Amended_________.

 

69L-31.012 Joint Stipulation of the Parties.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New 11-28-06, Formerly 59A-31.012, Repealed________.

 

69L-31.013 Petition Withdrawal.

(1) Prior to the issuance of a determination, the petitioner may voluntarily withdraw its Petition Form for Resolution of Reimbursement Dispute.

(2) The withdrawal must of a petition shall be in writing and must clearly indicate:

(a) The name of the health care provider or facility requesting withdrawal;

(b) The name of the carrier against which whom the reimbursement dispute petition has been initiated;

(c) The date(s) of service addressed on covered by the Petition Form petition; and

(d) The identity of the injured employee to whom medical services were delivered.

(3) Receipt The result of receipt by the Department of a written request for withdrawal of a Petition Form will result in closure of the Department’s file in the matter without further action petition shall be dismissal of the determination case by the Department.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a), (c) FS. History–New 11-28-06, Formerly 59A-31.013, Amended________.

 

69L-31.014 Overutilization Issues Raised in Reimbursement Dispute Resolution.

If the carrier asserts, in its Carrier Response Form that a basis for disallowing the health care provider’s claim for reimbursement is overutilization by the health care provider to Petition for Resolution of Reimbursement Dispute, asserts and submits documentation substantiating the assertion, that a basis for disallowing petitioner’s claim for payment is overutilization and the Department, in its discretion, determines that the reimbursement dispute cannot be resolved without addressing the overutilization issue, the Department will issue a determination, finding pursuant to Section 440.13(7), F.S., that the reimbursement dispute cannot be resolved under subsection Section 440.13(7), F.S., and is being converted to a proceeding under either subsection Sections 440.13(8) or and 440.13(11), F.S., ; or both.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b), 440.13(7)(c) FS. History–New 11-28-06, Formerly 59A-31.014, Amended________.

 

69L-31.016 Reimbursement Disputes Involving a Contract or Workers’ Compensation Managed Care Arrangement or Involving Compensability or Medical Necessity.

(1) When either the health care provider or carrier asserts that a contract between them establishes the amount of reimbursement to the health care provider, or where the carrier provided health care services to the injured worker through a workers’ compensation managed care arrangement pursuant to Section 440.134, F.S., the Department will not issue a finding that there has been any improper disallowance or adjustment. Instead, the determination will only indicate the reimbursement amount for the treatment established by the appropriate reimbursement schedules, practice parameters, and protocols of treatment under Chapter 440, F.S., to assist the health care provider and carrier in their independent application of the provisions of the contract or workers’ compensation managed care arrangement to resolve the dispute.   

(2) When the carrier asserts the treatment is not compensable or medically necessary and as a result does not reimburse, the Department will not issue a finding that there has been any improper disallowance or adjustment. Instead, the determination will only indicate the reimbursement amount for the treatment established by the appropriate reimbursement schedules, practice parameters, and protocols of treatment under Chapter 440, F.S., should compensability or medical necessity be later established.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (12)(a), 440.134(15) FS. History–New__________.

 

69L-31.017 Carrier and Health Care Provider Non-compliance

(1) The Department may issue an order compelling the carrier to correct its reimbursement practices. Failure by the carrier to correct such practices will result in the issuance of a willful violation pursuant to Rule 69L-24.007, F.A.C., in addition to any fines issued pursuant to paragraph 440.13(7)(f), F.S. Improper reimbursement practices by the carrier include, but are not limited to, the following:

(a) Failure to include a billed line item on an Explanation of Bill Review (“EOBR”) or notice of disallowance or adjustment of payment;

(b) Reducing the amount of a billed line item on an EOBR or notice of disallowance or adjustment of payment;

(c) Utilizing a drug pricing database other than the Medi-Span Master Drug Database for purposes of determining the average wholesale price for reimbursement of pharmaceuticals;

(d) Failure to provide final adjudication of a medical bill through payment, adjustment, disallowance, or denial within (45) calendar days of receipt of the medical bill, unless the medical bill is returned under subsection 69L-7.740(11), F.A.C., or unless compensability of the claim has been denied;

(e) Incorrectly reporting either the billed amount or the reimbursement amount when reporting medical bill data to the Division pursuant to Rule 69L-7.740, F.A.C.

(2) The Department may issue an order compelling the health care provider to correct its improper billing practices. Failure by the health care provider to correct such practices will constitute improper billing practices pursuant to paragraph 440.13(11)(a), F.S., and the health care provider will be subject to the penalties pursuant to paragraph 440.13(8)(b), F.S.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (8)(b), (11)(a), (12), 440.525 FS. History–New__________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Theresa Pugh, Program Administrator, Medical Services Section, Bureau of Monitoring and Audit, Division of Workers’ Compensation, Department of Financial Services

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Jeff Atwater, Chief Financial Officer, Department of Financial Services

DATE PROPOSED RULE APPROVED BY AGENCY HEAD:

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 23, 2016.