The purpose of this rule amendment is to address ministerial changes made to Rule 69L-7.602 and to update the Florida Workers' Compensation Medical EDI Implementation Guide (MEIG), 2006, to reflect its most current edition and additional data ...

DEPARTMENT OF FINANCIAL SERVICES
Divsion of Worker's Compensation

RULE NO: RULE TITLE
69L-7.602: Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule
PURPOSE AND EFFECT: The purpose of this rule amendment is to address ministerial changes made to Rule 69L-7.602 and to update the Florida Workers' Compensation Medical EDI Implementation Guide (MEIG), 2006, to reflect its most current edition and additional data reporting requirements. The effect of this rule amendment is to promote compliance by insurers and submitters with the requirements associated with electronic submission, filing, and reporting, as they relate to the Florida Workers' Compensation Medical Services Billing Rule, streamline the application of administrative fines and penalties on insurers for non-compliance, and update relevant reference material to reflect the most current edition.
SUMMARY: Rule amendment reflecting changes and updates to reference materials associated with the Florida Workers’ Compensation Medical Services Billing Rule.
SUMMARY OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
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.
SPECIFIC AUTHORITY: 440.13(4) FS. 440.15(3)(b) FS. 440.15(d), 440.185(5) FS., 440.525(2) FS. 440.591 FS. 440.593(5) FS.
LAW IMPLEMENTED: 440.09 FS. 440.13(2)(a) FS. 440.13(3) FS. 440.13(4) FS. 440.13(6) FS. 440.13(11) FS. 440.13(12) FS. 440.13(14) FS. 440.13(16) FS. 440.15(3)(b) FS. 440.15(d) FS. 440.185(5) FS. 440.185(9) FS. 440.20(6) FS. 440.525(2) FS. 440.593 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE TIME, DATE AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
TIME AND DATE: May 8, 2006, 10:00 a.m.
PLACE: Room 104J, Hartman Building, 2012 Capital Circle, S. E., 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: Don Davis, Division of Workers’ Compensation, Office of Data Quality and Collection, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4226, phone [phone]. 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: Don Davis, Division of Workers’ Compensation, Office of Data Quality and Collection, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4226, phone [phone].

THE FULL TEXT OF THE PROPOSED RULE IS:

69L-7.602 Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.

(1) No change.

(a) through (c) No change.

(d) “Billing” means the process by which a health care provider submits a claim to an insurer, service company/third party administrator (TPA) or any entity acting on behalf of the insurer, to receive reimbursement for medical services provided to an injured employee. 

(e) “Catastrophic Event” means the occurrence of an event outside the control of an insurer, submitter, service company/third party administrator (TPA)or any entity acting on behalf of the insurer, such as a natural disaster, an act of terrorism (including but not limited to cyber terrorism) or a telecommunications failure, in which recovery time will prevent an insurer, submitter, service company/third party administratorTPA or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and this rule.

(f) No change.

(g) “Charge Master” means a comprehensive coded list maintaineddeveloped by a hospital or an ambulatory surgical center for the purpose of verifyingrepresenting its usual charges as required by Section 440.13(12)(d), F.S.for specific services and supplies.

(h) “Claims-Handling Entity File Number” means the number assigned to the claim file by the insurer or service company/third party administratorTPA for purposes of internal tracking.

(i) No change.

(j) “Date Insurer Paid” or “Date Insurer Paid, Adjusted and Paid, Disallowed or Denied” means the date the insurer, service company/third party administratorTPA, submitter 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” or “Date Insurer Paid, Adjusted and Paid, Disallowed or Denied” means the date the insurer, service company/third party 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 paragraph (5)(l) for the requirement to accurately report the “date insurer paid”.

(k) “Date Insurer Received” 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 ofdelivered to, and manually or electronically date stamped by the insurer, service company/third party administratorTPA, submitter or any entity acting on behalf of the insurer.  See paragraph (5)(l) for the requirement to accurately report the “date insurer received”.

(l) “Deny” means to determine that no payment is to be made for a specific procedure code or other service reported by a health care provider to an insurer, service company/third party administratorTPA or any entity acting on behalf of the insurer on a bill.

(m) “Department” means Department of Financial Services as defined in Section 440.02(12), F.S. “Division” means the Division of Workers’ Compensation (DWC) as defined in Section 440.02(14), F.S.

(n) “Disallow” means to determine that no payment is to be made for a specific procedure code or other service reported by a health care provider to an insurer, service company/third party administratorTPA or any entity acting on behalf of the insurer for reimbursement, based on identification of a billing error, inappropriate utilization or over utilization, use of an incorrect billing form, only one line-item billed and the bill has an invalid code, or required information is inaccurate, missing or illegible.

(o) “Division” means the Division of Workers’ Compensation (DWC) as defined in Section 440.02(14), F.S.

(p)(o) “Electronic Filing” means the computer exchange of medical data from a submitter to the Ddivision in the standardized format defined in the Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065.

(q)(p) “Electronic Form Equivalent” means the format, provided in the Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065, to be used when a submitter electronically transmits required data to the Ddivision. Electronic form equivalents do not include transmission by facsimile, data file(s) attached to electronic mail, or computer-generated paper-forms.

(r)(q) “Electronically Filed with the Division” means the date an electronic filing has been received by the Ddivision and has successfully passed structural and data-quality edits.

(s)(r) “Entity” means any party, involved in the provision of or the payment for medical services, care or treatment rendered to the injured employee, excluding the insurer, service company/third party administratorTPA or health care provider as identified in this section.

(t)(s) “Explanation of Bill Review” (EOBR) means the notice of payment or notice of adjustment and payment, disallowance or denial sent by an insurer, service company/third party administrator or any entity acting on behalf of an insurer to a health care provider containing code(s) and code deor(s), in conformance with paragraph (5)(o) of this rulecodes and written explanation of an insurer’s reimbursement decision sent to the health care provider as notice of payment, denial, disallowance or adjustment.

(u)(t) “Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065” is the Florida Division of Workers’ Compensation’s reference document containing the specific electronic formats and data elements required for insurer reporting of medical data to the Ddivision.

(u) through (y) renumbered (v) through (z) No change.

(aa)(z)“Insurer Code Number” means the number the Ddivision assigns to each individual insurer, self-insured employer or self-insured fund.

(aa) through (ff) renumbered (bb) through (gg) No change.

(hh)(gg)“Report” means any form related to medical services rendered, in relation to a workers’ compensation injury, which is required to be filed with the Ddivision under this rule.

(ii)(hh) No change.

(jj)(ii)               “Service Company/Third Party Administrator (TPA) Code Number” means the number the Ddivision assigns to a service company, adjusting company, managing general agent oreach third party administrator, claims administrator or servicing company.

(kk)(jj)“Submitter” means an insurer, service company/TPA, entity or any other party acting as an agent or vendor on behalf of an insurer, service company/TPA, or any entity to fulfill any insurer responsibility to electronically transmit required medical data to the Ddivision.

(ll)(kk)“UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee, FebruaryApril 20065” (UB-92 manual) is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992).

(2) No change.

(a) Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev. 12/90); Form DFS-F5-DWC-9—A (Completion Instructions for Form DFS-F5-DWC-9); – A (comprised of three sets of completion instructions for use by health care providers, ambulatory surgical centers, and work hardening and pain management programs), Rev. 5/26/20055-26-05; Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form), Rev. 2/14/20065/26/2005; Completion Instructions for Form DFS-F5-DWC-10 – A, Rev. 5-26-05; Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form, Rev. 2002); Form DFS-F5-DWC-11—A (Completion Instructions for Form DFS-F5-DWC-11) – A, Rev. 5/May 26/, 2005; Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), Rev. 2/14/20065/26/2005); Completion/Submission Instructions for Form DFS-F5-DWC-25, Rev. May 26, 2005; and Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992) are hereby incorporated by reference into this rule.

1. A copy of the Form DFS-F5-DWC-9 can be obtained from the CMS web site: http://www.cms.hhs.gov/forms/. Completion instructions can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) web site: http://www.fldfs.com/WC/forms.html#7.

2. through 4. No change.

5. A copy of the Form DFS-F5-DWC-90 can be obtained from the CMS web site: http://cms.hhs.gov/forms/. Completion instructions can be obtained from the UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. FebruaryApril 20065) and subparagraph (4)(d)4.(e)5. of this rule.

(b) No Changes

1. No change.

2. The form provides all information required to be submitted to the Division, pursuant to the Florida Medical EDI Implementation Guide (MEIG), 2006, on the Form DFS-F5-DWC-10. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form.

(3) No change.

(a) UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. FebruaryJune 20065). A copy of this manual can be obtained from the Florida Hospital Association by calling [phone].

(b) The Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065. The Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065 can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/edi_med.htmlhttp://www.fldfs.com/WC/pdf/MedDataElecFilingManual2005_5-26-05.pdf.

(c) through (e) No change.

(f) The 20065 ICD-9-CM Professional for Hospitals, Volumes 1, 2 and 3, International Classification of Diseases, 9th Revision, Clinical Modification, Sixth Edition, Copyright 20052004, Ingenix, Inc.

(g) The Physician ICD-9-CM 20065, Volumes 1 & 2, International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 20052004, Ingenix, Inc.American Medical Association.

(h) through (k) No change.

(4) No change.

(a) No change.

(b) Each health care provider is responsible for submitting any additional form completion information and supporting documentation requested, in writing, by the insurer at the time of authorization, or at the time a reimbursement request is received.

(c) Insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee’s medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25.

1. through 2.  No change.

(d) 1. through  2. No change.

3. Regardless of the employment arrangement under which the services are rendered or the party submitting the bill, the following health care providers, who render direct billable services for which reimbursement is sought from an insurer, service company/TPA or any entity acting on behalf of the insurer, service company/TPA, shall enter his/her Florida Department of Health license number in Field 33 on the Form DFS-F5-DWC-9:

a. through  b. No change.

c. Any licensed non-physician health care providers whose licensure permits independent billing. who is seeking reimbursement under his or her license number issued by the Florida Department of Health.

4. No change.

a. Inpatient billing – Hospitals shall: in addition to filing a Form DFS-F5-DWC-90, attach an itemized statement with charges based on the facility’s Charge Master.

I. In addition to filing a Form DFS-F5-DWC-90, attach an itemized statement with charges based on the facility’s Charge Master; and

II. Enter the ZIP Code applicable to the hospital’s physical location in Form Locator 84 – ‘Remarks’, on the DFS-F5-DWC-90. The ZIP Code must be the first entry within the ‘Remarks’ area when multiple entries are made in Form Locator 84; and

b. No change.

I. In addition to filing a Form DFS-F5-DWC-90, enter the CPT, HCPCS, or unique workers’ compensation code (provided in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual adopted in Rule 69L-7.020, F.A.C.) in Form Locator 44 on the Form DFS-F5-DWC-90, to bill outpatient radiology, clinical laboratory and physical, occupational or speech therapy charges; and

II. Make written entry “scheduled” or “non-scheduled” in Form Locator 84 – ‘Remarks’ on the DFS-F5-DWC-90, directly after entry of the hospital’s physical location ZIP code, when billing outpatient surgery or outpatient surgical services; andEnter a surgical CPT code in Form Locator 44 when billing outpatient surgery or surgical services; and

III. Enter the date of service on Form DFS-F5-DWC-90, in Form Locator 45, for outpatient billing; and

III.IV.Attach an itemized statement with charges based on the facility’s Charge Master if there is no line item detail shown on the Form DFS-F5-DWC-90.; and

V. Enter the ZIP Code applicable to the hospital’s physical location in Form Locator 84 – ‘Remarks’ on the DFS-F5-DWC-90.  The ZIP Code must be the first entry within the ‘Remarks’ area when multiple entries are made in Form Locator 84.

5. Certified, licensed physician assistants, anesthesia assistants and registered nurse first assistants who provide services as a surgical assistantce, in lieu of a second physician, on procedures with codes permitting an assistant surgeon-physician shall bill on a Form DFS-F5-DWC-9 entering the CPT code(s) plus modifier(s), which represent the service(s) rendered, in Field 24D, and must enter his/her Florida Department of Health license number in Field 33.

6. Ambulatory Surgical Centers (ASCs) shall bill on a Form DFS-F5-DWC-9 with itemized line-item charges based on the ASC’s Charge Master.

7. through 8. No change.

9. No change.

a. through e. No change.

f. Dispensing physicians, physician assistants or ARNPs shall bill by entering code 99070 in Field 24D, on a Form DFS-F5-DWC-9, when supplying over-the-counter drugs and shall submit documentationan invoice indicating the name, dosage, package size and cost of the drug(s).

g. No change.

10. No change.

11. Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) must accurately complete the Form DFS-F5-DWC-9 and submit the form to the insureron the date of service. A Form DFS-F5-DWC-9 must be submitted to the insurer within 30 calendar days following the date of each service.

12. Health care providers and other insurer-authorized providers rendering health care services reimbursable under workers’ compensation, whose billing requirements are not otherwise specified in this rule (e.g. home health agencies, independent, non-hospital based ambulance services, transportation services, translation services, etc.), shall bill on their invoice or business letterhead. These providers shall not submit the Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.

(e) No change.

1. Bills shall be legibly and accurately completed by all health care providers, regardless of location or reimbursement methodology, as set forth in this paragraphsection.

2. Billing elements required by the Ddivision to be completed by a health care provider are identified in specific Form DFS-F5-DWC-9 – A (completion instructions), available at the following websites:

a. through c. No Changes

3. Billing elements required by the Ddivision to be completed for Pharmaceutical or Medical Supplier Billing are identified in specific Form DFS-F5-DWC-10 (completion instructions) available at website: http://www.fldfs.com/WC/forms.html#7http://www.fldfs.com/wc/pdg/DWC-10.pdf.

4. Billing elements required by the Ddivision to be completed for Dental Billing are identified in specific Form DFS-F5-DWC-11– A (completion instructions), available at website: http://www.fldfs.com/WC/forms.html#7.

5. Billing elements required by the Ddivision to be completed for Hospital Billing are identified in the UB-92 Manual and subparagraph (4)(d) 4. of this rule.

6. An insurer can require a health care provider to complete additional data elements that are not required by the Ddivision on Forms DFS-F5-DWC-9 or DFS-F5-DWC-11.

(f) Health Care Provider Bill Submission/Filing and Reporting Requirements.

1. through 2. No change.

3. Medical claim form(s) or bill(s) shall be filed by the health care provider with an insurer, service company/TPA or any entity acting on behalf of the insurer., according to the following requirements: The health care provider must submit required documentation that supports the medical necessity of services rendered. This requirement does not apply to Pharmacies, Medical Suppliers, Ambulatory Surgical Centers or Hospitals except as requested in conjunction with an insurer audit.

a. Health Care Providers (excluding hospitals):

Within 30 calendar days of initial or additional service or treatment and accompanied by required documentation that supports medical necessity. This requirement includes Pharmacies, Medical Suppliers, and Ambulatory Surgical Centers.

b. Hospitals:

(I) Within 30 calendar days following emergency room or initial outpatient treatment.

(II) Within 30 calendar days of an injured employee’s discharge from an in-patient hospital stay or follow-up outpatient treatment.

(5) No change.

(a) An insurer is responsible for meeting its obligations under this rule regardless of any business arrangements with any service company/TPA, submitter or any entity acting on behalf of the insurer under which claims are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Ddivision.

(b) At the time of authorization for medical service(s) or at the time a reimbursement request is received, an insurer shall notify each health care provider, in writing, of additional formfrom completion requirements or supporting documentation that are necessary for reimbursement determinations. 

(c) No change.

(d) Insurers, service company/TPAs or entities acting on behalf of insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of an injured employee’s medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25. 

(e) Required data elements on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, and DFS-F5-DWC-90, for both medical only and lost-time cases, shall be filed with the Ddivision within 45-calendar days of insurer, service company/TPA or any entity acting on behalf of the insurer, payment, adjustment and payment, disallowance or denial. This 45-calendar day requirement includes initial submission and correction and re-submission of all errors identified in the “Medical Claim Processing Report”, as defined in the Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20065.

(f) An insurer shall be responsible for accurately completing required data filed with the Ddivision, as of the effective date of this rule, pursuant to the Florida Workers’ CompensationMedical EDI Implementation Guide (MEIG), 20065 and subparagraphs (4)(e)2.– 5. of this rule.

(g) When an injured employee does not have a Social Security Number or division-assigned number, the insurer must contact the Ddivision via information provided on the following website: http://www.fldfs.com/WC/organization/odqc.html (under Records Management) to obtain a division-assigned number prior to submitting the medical report to the Ddivision.

(h) An insurer, or service company/TPA or any entity acting on behalf of an insurer must report to the Ddivision the procedure, diagnosis or modifier code(s) or amount(s) charged, as billed by the health care provider.

(i) An insurer, service company/TPA or any entity acting on behalf of the insurer shall manually or electronically date stamp accurately completed Forms DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or a submitter shall date stamp the electronic form equivalent onwith the “date insurer received” as defined in paragraph (1)(k) of this rule. 

(j) No change.

1. No change.

2. An invalid code is used or a required code is omitted and is the only line-item billed on the form; or

3. Required billing information is illegible, inaccurate, or omitted on the form.

(k) An insurer, service company/TPA or any entity acting on behalf of the insurer shall pay, adjust and pay, disallow or deny billed charges within 45-calendar days from the date insurer received, pursuant to Section 440.20(2)(b), F.S.

(l) In the medical bill claims-handling process, the receipt of medical bills may be based upon receipt by the insurer or there may be an “entity” acting on behalf of an insurer for purposes of receipt of medical bills. Likewise, the payment of medical bills may be based upon payment by the insurer or there may be an “entity” acting on behalf of an insurer for purposes of payment of medical bills. Therefore, to properly reflect receipt date and payment date of medical bills, the medical bill reporting process must accommodate various receipt and payment options.

1. The receipt and payment option utilized by an insurer and reported to the Division must meet one of the following:

a. Both receipt and payment of medical bills are handled by the insurer.  This option may be utilized only when the “date insurer received” is the date the insurer gained possession of the health care provider’s medical bill, and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer. This option may not be utilized when a health care provider is required by the insurer to submit medical billings to any “entity” other than the insurer.  

b. Both receipt and payment of medical bills are handled by any “entity” acting on behalf of the insurer. This option may be utilized only when the “date insurer received” is the date the “entity” acting on behalf of the insurer gained possession of the health care provider’s medical bill, and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the “entity” acting on behalf of the insurer. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.  

c. Receipt of medical bills is handled by the insurer and payment of medical bills is handled by the “entity” acting on behalf of the insurer. This option may be utilized only when the “date insurer received” is the date the insurer gained possession of the health care provider’s medical bill, and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the “entity” acting on behalf of the insurer. This option may not be utilized when a health care provider is required by the insurer to submit medical billings to any “entity” other than the insurer.

d. Receipt of medical bills is handled by any “entity” acting on behalf of the insurer and payment of medical bills is handled by the insurer. This option may be utilized only when the “date insurer received” is the date the “entity” acting on behalf of the insurer gained possession of the health care provider’s medical bill, and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer.  This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer. 

2. The insurer must document the option(s) selected in subparagraph (5)(l)1. of this rule, must identify the specific effective date for each option selected, must specify the role of each “entity” acting on the insurers behalf in the option selected, and must make this written documentation available to the Division for audit purposes pursuant to Section 440.525, F.S.  When the insurer selects options b., c., or d. from subparagraph (5)(l)1. of this rule, there must be written documentation from the “entity” acknowledging its responsibilities concerning “date insurer received” and “date insurer paid” for each option. The written documentation maintained by the insurer must identify the applicability of the options selected in sufficient detail to allow verification of the coding of each medical bill under subparagraph (5)(l)4. of this rule.

3. An insurer and entity may select multiple options for medical bill claims handling between the insurer and the entity based on business practices or whether medical bills are submitted to the insurer electronically or on paper.

4. The option in subparagraph (5)(l)1. of this rule selected by the insurer must be identified on each medical report electronic submission to the Division, in accordance with paragraph (6)(e) of this rule, and must utilize the following coding methodology:

a. If the “date insurer received” is the date the insurer gains possession of the health care provider’s medical bill and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x”1 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the Florida Medical Implementation EDI Guide (MEIG), 2006.)  When submitting Payment Code “x”1 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(s) of this rule is involved in the medical bill claims-handling processes related to “date insurer received” or “date insurer paid”.

b. If the “date insurer received” 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” 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 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x”2 to the Division, the insurer is declaring that the specified “entity” is acting on behalf of the insurer for purposes of the medical bill claims-handling processes related to “date insurer received” and ”date insurer paid”.

c. If the “date insurer received” is the date the insurer gains possession of the health care provider’s medical bill and “date insurer paid” 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 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x”3 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(s) of this rule is involved in the medical bill claims-handling process related to “date insurer received”.

d. If the “date insurer received” 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” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x”4 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the Florida Medical Implementation EDI Guide (MEIG), 2006.)  When submitting Payment Code “x”4 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(s) is involved in the medical bill claims-handling processes related to “date insurer paid”.

(m)(l)               An insurer, service company/TPA or any entity acting on behalf of the insurer, when reporting paid medical claims data to the Ddivision, shall report the dollar amount paid by the insurer or reimbursed to the employee for healthcare service(s) or supply(ies). When reporting disallowed or denied charges, the dollar amount paid shall be reported as $0.00.

(n)(m)An insurer, service company/TPA or any entity acting on behalf of the insurer shall not report as medical payment data, those payments made for failed appointments for scheduled independent medical examinations.

(o)(n)              A submitter, filing electronically, shall submit to the Ddivision the Explanation of Bill Review (EOBR) code(s), relating to the adjudication of each line item billed and:

1. No change.

2. Use the EOBR codes and code deors as follows:

a. through b. No change.

c. 03 Services related to a denied work injury: Form DFS-F2-DWC-12 on file with the Ddivision.

d. No change.

e. 05 Documentation does not support the level, intensity, frequency, or duration or provision of service(s) billed. (Insurer must specify to the health care provider.)

f. through j. No change.

k. 11 Reimbursement is based on insurer re-coding. (Insurer must specify to the health care provider.)

l. No change.

m. 13 Reimbursement is included in the allowance of another service. (Insurer must specify procedure to the health care provider.)

n. 14  Hospital Iitemized statement not submitted with billing form.

o. 15 Invalid procedure code. (Use only when other valid procedure codes are present.)

p. No change.

q. 17 Required supplemental documentation not filed with the bill. (Insurer must specify required documentation to the health care provider.)

r. No change.

s. No change.

t. 20 Other: Unique EOBR code deorion. Use of EOBR code “20” is restricted to circumstances when an above-listed EOBR code does not explain the reason for payment, adjustment and payment, disallowance or denial of payment. When using EOBR code “20”, an insurer must reflect code “20” and include the specific explanation of the code on the EOBR sent to the health care provider. The insurer, service company/TPA or any entity acting on behalf of the insurer must maintain a standardized EOBR code deorion list.

(p)(o) An insurer, service company/TPA, submitter or any entity acting on behalf of the insurer shall make available to the Ddivision and to the Agency, upon request and without charge, a legibly reproduced copy of the electronic form equivalents or Forms DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-25, DFS-F5-DWC-90, supplemental documentation, proof of payment, EOBR and standardized EOBR code “20” deorion list, and the insurer written documentation required in subparagraph (5)(l)2. of this rule.

(q)(p) An insurer, service company/TPA or any entity acting on behalf of the insurer to pay, adjust and pay, disallow or deny a filed bill shall submit to the health care provider an Explanation of Bill Review, utilizing the EOBR codes and code deorsions, as set forthlisted in paragraph (on) of this section, and shall include the insurer name and specific insurer contact information.  An insurer, service company/TPA or any entity acting on behalf of the insurer shall notify the health care provider of notice of payment or notice of adjustment and payment, disallowance or denial only through an EOBR. An EOBR shall specifically state that the EOBR constitutes notice of disallowance or adjustment of payment within the meaning of Section 440.13(7), F.S. An EOBR shall 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” for the purpose of receiving the petitioner’s service of a copy of a petition for reimbursement dispute resolution by certified mail, pursuant to Section 440.13 (7)(a), F.S.

(r)(q) No change.

(6) Insurer Electronic Medical Report Filing to the Ddivision. 

(a) Effective March 16, 2005, all required medical reports shall be electronically filed with the Ddivision by all insurers.

1. Additionally, an insurer shall be responsible for accurately completing the electronic record-layout programming requirements for the reporting of the Form DFS-F5-DWC-9 Claim Detail Record Layout – Revision “C” and the Form DFS-F5-DWC-10 Claim Detail Record Layout – Revision “C”, Form DFS-F5-DWC-11 Claim Detail Record Layout – Revision “C” and Form DFS-F5-DWC-90 Claim Detail Record Layout – Revision “C” in accordance with the Florida Workers’ Compensation Medical Implementation Guide (MEIG), 2005, to the Division in accordance with the phase-in schedule as denoted below in sub-subparagraphs a., b., and c. of this section. The electronic record layout for Form DFS-F5-DWC-9 in the MEIG, 2005, adds the new field 30A for submission of the pre-payment/employee payment indicator and the new field 31A for submission of the duplicate override indicator and adds the new field 18B for submission of the National Drug Code (NDC) number.  The electronic record layout for Form DFS-F5-DWC-10 in the MEIG, 2005, adds the new field 24A for submission of the pre-payment/employee payment indicator and the new field 25A for the submission of the duplicate override indicator and adds a claim detail record layout, which includes form fields 7, 8, 9, 10, 11, 12, 13, 14 and 15 for Section 2 – Preion Drugs. The electronic record layout for Form DFS-F5-DWC-11 in the MEIG, 2005, adds the new field 27A for submission of the pre-payment/employee payment indicator and the new field 28A for submission of the duplicate override indicator. The electronic record layout for Form DFS-F5-DWC-90 in the MEIG, 2005, adds the new field 40A for submission of the pre-payment/employee payment indicator and the new field 41A for submission of the duplicate override indicator. The conversion implementation schedule is as follows:

a. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “B”), between August 2, 2004 and November 9, 2004 shall begin testing on December 5, 2005 and shall be in production with the new record layouts no later than January 13, 2006.

b. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “B”), between November 10, 2004 and February 28, 2005 shall begin testing on January 16, 2006 and shall be in production with the new record layouts no later than February 24, 2006.

c. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “B”), between March 1, 2005 and the effective date of this rule shall begin testing on February 27, 2006 and shall be in production with the new record layouts no later than April 7, 2006.

2. The Division will, resources permitting, allow submitters that volunteer to complete test transmission to production transmission processes earlier than the schedule denoted above. Each voluntary submitter shall have six weeks to complete test transmission to production transmission processes, for all electronic form equivalents, that comply with requirements set forth in the Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 2005.

(b) Required data elements shall be submitted in compliance with the instructions and formats as set forth in the Florida Workers’ CompensationMedical EDI Implementation Guide (MEIG), 20065.

(c) The Ddivision will notify the insurer on the “Medical Claim Processing Report” of the corrections necessary for rejected medical reports to be electronically re-filed with the Ddivision. An insurer shall correct and re-file all rejected medical claim reports to meet the filing requirements of paragraph (5)(e) of this rule.

(d) Submitters who experience a catastrophic event resulting in the insurer’s failure to meet the reporting requirements in paragraph (5)(e) of this rule, shall submit a written request within 153 business days of the catastrophic failure to the Ddivision for approval to submit in an alternative reporting method and an alternative filing timeline. Approval must be obtained from the Ddivision’s Office of Data Quality and Collection, 200 East Gaines Street, Tallahassee, Florida 32399-4226. Approval to submit in an alternative reporting method and an alternative filing timeline shall be granted if a catastrophic event beyond the control of the submitter prevents electronic submission.

(e) Effective September 1, 2006, each insurer shall be responsible for accurately completing the additional electronic Revision C record-layout programming requirements in accordance with the Florida Medical EDI Implementation Guide (MEIG), 2006.  The additional requirements include:

1. The electronic record layout in the Florida Medical EDI Implementation Guide (MEIG), 2006, for Form DFS-F5-DWC-10 adds the new Field 16B for submission of the Amount Paid by Insurer.

2. The electronic record layout in the Florida Medical EDI Implementation Guide (MEIG), 2006, amends the Payment Plan Code values in Appendix D for Field 23A on the Form DFS-F5-DWC-9, Field 24A on the Form DFS-F5-DWC-10, Field 24A on the Form DFS-F5-DWC-11, and Field 36A on the Form DFS-F5-DWC-90 in order to collect and specify the insurer’s particular medical bill claims-handling arrangements for “date insurer received” and for “date insurer paid, adjusted and paid, disallowed, or denied” for each individual medical bill form type. The data field name is changed from “Payment Plan Code” to “Payment Code” to reflect these modifications to the values.

3. The designation of the claims-handling arrangement affirms the option selected by the insurer in subparagraph (5)(l)1. of this rule.

(7) Insurer Administrative Penalties and Administrative Fines for Untimely Health Care Provider-Payment or Disposition of Medical Bills.

(a) Insurer administrative penalties for untimely provider-payment or disposition of medical bills. The Ddepartment shall impose insurer administrative penalties for failure to comply with the payment, adjustment and payment, disallowance or denial requirements pursuant to Section 440.20(6)(b), F.S. Timely performance standards for timely payments, adjustments and payments, disallowances or denials, reported on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90, shall be calculated and applied on a monthly basis for each separate form category that was received within a specific calendar month.

(b) Insurer administrative fines for failure to submit, untimely submission, filing and reporting of medical data requirements.Pursuant to Section 440.185(9), F.S., the Ddepartment shall impose insurer administrative fines for failure to comply with the submission, filing or reporting requirements of this rule. Insurer administrative fines shall be applied as follows:

1. Calculated on a monthly basis for each separate form category (Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, and DFS-F5-DWC-90) received and accepted by the Ddivision within a specific calendar month; and

2. Insurers are required to report all medical reports timely pursuant to paragraph (5)(e) of this rule. Insurers that fail to submit a minimum of 95% of all medical reports timely are subject to an administrative fine. Each untimely filed medical report which falls below the 95% requirement is subject to the following penalty schedule:Imposed for each failure to file, untimely filed, rejected and not re-submitted, or rejected and re-submitted untimely medical data report according to the following schedule:

a. 1 – 3015 calendar days late $510.00;

b. 3116 – 6030 calendar days late $120.00;

c. 631 – 9045 calendar days late $2530.00;

d. 91 or greater46 – 60 calendar days late $10040.00.;

e. 61 – 75 calendar days late $50.00;

f. 76 – 90 calendar days late $100.00; and

g. 91 calendar days or greater $500.00.

3. Each medical report that does not pass the electronic reporting edits shall be rejected by the Division and considered not filed pursuant to paragraph (5)(e) of this rule. If the medical report remains rejected and not corrected, resubmitted and accepted by the Division for greater than 90 days, an administrative fine shall be assessed in the amount of $100.00 for each such medical report. Rejected and not resubmitted medical reports will not be included in the 95% timely reporting requirement.

4. Untimely filed medical reports for a given month will be excluded from the administrative fine set forth in subparagraph (7)(b)3. above as falling within the performance standard between 100% and 95% in the following order:

a. Medical Reports filed 1 – 30 calendar days late; then

b. Medical Reports filed 31 – 60 calendar days late; then

c. Medical Reports filed 61 – 90 calendar days late; then

d. Medical Reports filed 91+ calendar days late.

Specific Authority 440.13(4) FS., 440.15(3)(b), (d) FS., 440.185(5) FS., 440.525(2) FS., 440.591 FS., 440.593(5) FS. Law Implemented 440.09 FS., 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16) FS., 440.15(3)(b), (d) FS., 440.185(5), (9) FS., 440.20(6) FS., 440.525(2) FS., 440.593 FS. History–New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, Amended________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Don Davis, Office of Data Quality and Collection, Division of Workers’ Compensation.
NAME OF SUPERVISOR OR PERSON WHO APPROVED THE PROPOSED RULE: Dan Sumner, Assistant Director, Division of Workers’ Compensation.
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: April 4, 2006
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: December 30, 2005