The purpose of the proposed rules is to substantially reword the existing rule to establish uniform procedures and form filing requirements for health care providers and employer/carriers regarding AHCA resolution of workers’ compensation ...  

  • Health Quality Assurance

    RULE CHAPTER NO.: RULE CHAPTER TITLE:

    59A-31 Disputed Reimbursement Rule

    RULE NOS.: RULE TITLES:

    59A-31.001 Disputed Reimbursement Avoidance

    59A-31.002 Disputed Reimbursement

    59A-31.003 Petition Form

    59A-31.004 Carrier Response Form

    59A-31.005 Petition Requirements

    59A-31.006 Consolidation of Petitions

    59A-31.007 Service of Petition on Carrier and Affected Parties

    59A-31.008 Computation of Time

    59A-31.009 Carrier Response Requirements

    59A-31.010 Effect of Non-Response by Carrier

    59A-31.011 Complete Record

    59A-31.012 Petition Withdrawal

    59A-31.013 Overutilization Issues Raised in Reimbursement Dispute Resolution

    59A-31.014 Managed Care Arrangements

    PURPOSE AND EFFECT: The purpose of the proposed rules is to substantially reword the existing rule to establish uniform procedures and form filing requirements for health care providers and employer/carriers regarding AHCA resolution of workers’ compensation reimbursement disputes.

    SUBJECT AREA TO BE ADDRESSED: Workers’ compensation medical services reimbursement disputes between health care providers and carriers.

    SPECIFIC AUTHORITY:  440.13(7) FS., 440.134(25)(e) FS., 440.591 FS.

    LAW IMPLEMENTED: 440.13(7) FS

    A RULE DEVELOPMENT WORKSHOP WILL HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

    DATE AND TIME: April 12, 2006, 10:00 a.m.

    PLACE:  104-J Hartman Building, 2012 Capital Circle, Southeast, Tallahassee, Florida

    THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT IS: Beverly J. Williams, Medical Health Care Program Analyst AHCA, Workers’ Compensation Unit, 2012 Capital Circle South East, Tallahassee, Florida 32399-4232

     

    THE PRELIMNARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

     

    (Substantial rewording of Rule Chapter 59A-31 follows. See Florida Administrative Code for present text.)

     

    RESOLUTION OF WORKERS’ COMPENSATION REIMBURSEMENT

    DISPUTES DISPUTED REIMBURSEMENT

     

    59A-31.001  Disputed Reimbursement Avoidance.

    Specific Authority 440.13(7) FS. Law Implemented 440.13(2)(a),(i) FS. HistoryNew 5-15-91, Formerly 38F-7.517, 4L-7.517, Repealed_________.

     

    59A-31.002  Disputed Reimbursement

    Specific Authority 440.13(7) FS. Law Implemented 440.13(2)(a),(i) FS. HistoryNew 5-15-91, Formerly 38F-7.517, 4L-7.517, Repealed________.

     

    59A-31.003 Petition Form.

    (1) The Petition for Resolution of Reimbursement Dispute Form (AHCA Form XXXX) is hereby incorporated by reference. This form may be obtained on the internet at http://www.fldfs.com/wc/forms.html or by contacting the Agency 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 on the Petition for Resolution of Reimbursement Dispute form. Any submission seeking to contest the disallowance or adjustment of payment by a carrier pursuant to Section 440.13(7)(a) F.S., which does not include a completed Petition for Resolution of Reimbursement Dispute form will be dismissed.

    Specific Authority 440.13(7)(e) FS. Law Implemented 440.13(7)(a) FS. HistoryNew________.

     

    59A-31.004  Carrier Response Form.

    (1)  The Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA  Form YYYY) is hereby incorporated by reference. This form may be obtained on the Internet at http://www.fldfs.com/wc/forms.html or by contacting the Agency at (850)413-1613. 

    (2) The Carrier Response to Petition for Resolution of Reimbursement Dispute form shall be considered a required element of the requested documentation to the Agency under Section 440.13(7)(b) F.S. The Carrier Response to Petition for Resolution of Reimbursement Dispute form shall be the only form accepted by the Agency upon which a carrier may submit to the Agency its response to a Petition for Resolution of Reimbursement Dispute form. Any submission by a carrier pursuant to Section 440.13(7)(b) F.S. which does not include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute form shall constitute failure to submit requested documentation to the Agency. 

    Specific Authority 440.13(7)(e) FS.  Law Implemented 440.13(7)(b) FS. HistoryNew________.

     

    59A-31.005 Petition Requirements.

    (1) All documents and records that support the allegations contained in the petition must accompany the petition. 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 Explanation of Bill Review received from the carrier providing notice of disallowance or adjustment of payment in this dispute. If the Explanation of Bill Review does not contain a date stamp, which clearly reflects date of receipt, documentation of a verifiable login process establishing date of receipt of the Explanation of Bill Review must be submitted. An affidavit attesting to date of receipt will not be accepted as proof of date of receipt. 

    (b) A copy of each medical bill or request for reimbursement for which payment was disallowed or adjusted by the carrier on the contested Explanation of Bill Review(s).

    (c) All medical documentation and records submitted to the carrier in support of the medical 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.

    (e) Documentation of carrier authorization for non-emergency treatment for the date(s) of service covered by the petition.

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

    (3) Each allegation contained in the petition must be accompanied by documents and records that support the allegation. If a petition contains multiple allegations which form the basis for contesting the disallowance or adjustment of payment by the carrier, any allegation that the Agency determines is not supported by the documents and records accompanying the petition will be dismissed with prejudice.

    Specific Authority 440.13(7)(e) FS., 440.591 FS. Law Implemented 440.13(7)(a) FS. HistoryNew ________.

     

    59A-31.006  Consolidation of Petitions.

    (1)  If multiple petitions have been filed by petitioner contesting disallowance or adjustment of payment by the same carrier, the Agency may, in its discretion, consolidate the petitions into a single determination. 

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

    Specific Authority 440.13(7)(e), FS., 440.591 FS. Law Implemented 440.13(7)(e) FS.  HistoryNew________.

     

    59A-31.007 Service of Petition on Carrier and Affected Parties.

    (1) A Petition for Resolution of Reimbursement Dispute must be served on the carrier and all affected parties by United States Postal Service (USPS) certified mail. Service on the carrier shall include all documents and records submitted to the Agency in support of the petition.

    (2) The petitioner shall effectuate service on the carrier and on all affected parties by serving a copy of the petition and all documents and records in support of the petition, by United States Postal Service (USPS) certified mail on the entity identified on the Explanation of Bill Review as the entity the carrier designates to receive service on behalf of the carrier and all affected parties. If the Explanation of Bill Review 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 paragraph 69L-7.602(5)(q), F.S., the petitioner may effectuate service of the petition on the carrier and all affected parties by serving a copy of the petition and all documents and records in support of the petition by United States Postal Service (USPS) certified mail, on the entity who issued the Explanation of Bill Review at the address from which the Explanation of Bill Review was issued.

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

    (4) If a carrier has not been properly served in accordance with this subsection, the petitioner will be notified by the Agency of the deficiency in service. The petitioner shall have 10 calendar days from receipt of the notice of deficiency in service to provide the Agency with proof of proper service. If the Agency does not receive proof of proper service within 10 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 and all documents and records in support of the 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 Agency to confirm mailing.

    Specific Authority 440.13(7)(e) FS., 440.591 FS. Law Implemented 440.13(7)(a) FS. History–New_________.

     

    59A-31.008  Computation of Time. 

    (1) Pursuant to paragraph 69L-7.602(5)(q), F.A.C., notice of disallowance or adjustment of payment, which begins the 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 30 day time period within which a petition must be served upon the Agency 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. An affidavit attesting to date of receipt will not be accepted as proof of date of receipt.

    (2) Petitioning the Agency shall be effectuated upon service of the petition upon the Agency. The timeliness of a Petition for Resolution of Reimbursement Dispute shall be calculated based upon service of the petition upon the Agency. Service upon the Agency shall be by United States Postal Service (USPS) mail or by common carrier. If service is by United States Postal Service mail, the date of service shall be the postmark date. If service is by common carrier, the date of service shall be the common carrier pick-up date. 

    (3) Carrier date of receipt of the petition by certified mail will be established by reference to the United States Postal Service (USPS) certified mail receipt date. Timely submission by the carrier of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and accompanying documentation to the Agency shall be determined based upon the date of service of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and accompanying documentation to the Agency. If service is by United States Postal Service mail, the date of service shall be the postmark date. If service is by common carrier, the date of service shall be the common carrier pick-up date. 

    (4)  Neither the request for, nor the conducting of, an on-site audit performed under the Florida Workers’ Compensation Reimbursement Manual for Hospitals or referral of the health care provider for peer review consultation or independent medical examination shall toll the timeframe for petitioning the Agency for the resolution of a reimbursement dispute as set forth in s. 440.13(7(a) F.S. or for the carrier to submit requested documentation under s. 440.13(7)(b) F.S.

    Specific Authority 440.13(7)(e) FS., 440.591 FS. Law Implemented 440.13(7)(a),(b) FS. History–New _________.

     

    59A-31.009 Carrier Response Requirements.

    (1) The Carrier Response to Petition for Resolution of Reimbursement Dispute form, accompanied by all requested information, must be served on the Agency within 10 days after receipt of a copy of the petition by certified mail. The carrier’s response to the petition must include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA form YYYY). Failure of the carrier to meet these requirements constitutes waiver of all objections to the petition.

    (2) Documents and records accompanying the carrier’s Response to Petition for Resolution of Reimbursement Dispute form must be in hard copy.

    Specific Authority 440.13(7)(e) FS., 440.591 FS. Law Implemented 440.13(7)(b) FS. HistoryNew________.

     

    59A-31.010 Effect of Non-Response by Carrier.

    (1) Failure of a carrier to timely submit a Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA form YYYY) and accompanying documentation substantiating its disallowance or adjustment of payment constitutes a waiver of all objections to the petition.  Waiver of all objections to the petition shall result in the Agency determination and final order being based solely upon the allegations and supporting documentation submitted by the petitioner.

    (2) If a carrier has waived all objections to the petition under Section 440.13(7), F.S., with regard to a particular disallowance, adjustment or denial of payment, the carrier has also waived relief under s. 440.13(8) F.S. or s. 440.13(11) F.S. with regard to the payment(s) that was in dispute in the petition under Section 440.13(7), F.S.

    Specific Authority 440.13(7) FS., 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New_________.

     

    59A-31.011 Complete Record.

    The evidentiary record upon which the Agency determination will be made shall be the Petition for Resolution of Reimbursement Dispute and all supporting documents and records accompanying the petition and the Carrier’s Response to the Petition for Resolution of Reimbursement Dispute and all accompanying documents.

    Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(c), FS. HistoryNew________.

     

    59A-31.012  Petition Withdrawal.

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

    (2) Withdrawal 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 whom the petition has been initiated;

    (c) the date(s) of service covered by the petition; and,

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

    (3) The result of receipt by the Agency of a request for withdrawal of a petition shall be dismissal of the determination case by the Agency.

    Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a), (c), FS. HistoryNew ________.

     

    59A-31.013  Overutilization Issues Raised in Reimbursement Dispute Resolution.

    If the carrier, in its response to the petition for Resolution of Reimbursement Dispute, asserts and submits documentation substantiating that a basis for disallowing petitioner’s claim for payment is  overutilization and the Agency, in its discretion, determines that the reimbursement dispute cannot be resolved without addressing the overutilization issue, the Agency will issue a determination pursuant to Section 440.13(7), F.S.  that the reimbursement dispute can not be resolved under Section 440.13(7), F.S., and is being converted to a proceeding under Section 440.13(8), F.S. and/or Section 440.13(11), F.S.

    Specific Authority 440.13(7)(e), 440.591, F.S. Law Implemented 440.13(7)(b),(c) F.S. HistoryNew________.

     

    59A-31.014 Managed Care Arrangements.

    A health care provider may not elect to contest under Section 440.13(7), F.S. disallowance or adjustment of payment by a carrier for services rendered pursuant to a managed care arrangement unless the managed care plan of operation pursuant to Section 440.134(6)(c)(7) F.S., specifically provides for reimbursement dispute resolution pursuant to Section 440.13(7) F.S.

    Specific Authority 440.13(7)(e), 440.134(25)(e), 440.591 FS. Law Implemented 440.13(7) FS.. History–New________.

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Document Information

Subject:
Workers’ compensation medical services reimbursement disputes between health care providers and carriers.
Purpose:
The purpose of the proposed rules is to substantially reword the existing rule to establish uniform procedures and form filing requirements for health care providers and employer/carriers regarding AHCA resolution of workers’ compensation reimbursement disputes.
Rulemaking Authority:
440.13(7) FS., 440.134(25)(e) FS., 440.591 FS.
Law:
440.13(7) FS
Contact:
Beverly J. Williams, Medical Health Care Program Analyst AHCA, Workers’ Compensation Unit, 2012 Capital Circle South East, Tallahassee, Florida 32399-4232.
Related Rules: (14)
59A-31.001. Disputed Reimbursement Avoidance (Repealed)
59A-31.002. Disputed Reimbursement Resolution
59A-31.003. Petition Form
59A-31.004. Carrier Response Form
59A-31.005. Petition Requirements
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