DEPARTMENT OF FINANCIAL SERVICES
Division of Workers' Compensation
RULE NO.:RULE TITLE:
69L-7.020Florida Workers' Compensation Health Care Provider Reimbursement Manual
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 47 No. 24, February 5, 2021 issue of the Florida Administrative Register.
69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
(1) through (3) No change.
PROPOSED EFFECTIVE DATE: Upon ratification ratification by the Legislature
Rulemaking Authority 440.13(13)(b), 440.591 FS. Law Implemented 440.13(7), (12), (13)(b) FS. History–New 10-1-82, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, 4L-7.020, Amended 12-4-03, 1-1-04, 7-4-04, 5-9-05, 9-4-05, 11-16-06, 10-18-07, 2-4-09, 7-1-16, 7-1-17,______.
Editorial Note: Ratified by Ch. 2016-203, LOF.
The Florida Workers’ Compensation Health Care Provider Reimbursement Manual (HCP RM), incorporated by reference in subsection 69L-7.020(1), is modified as follows (page references are to the previous version):
Page 6:
In the Purpose section, “TPA” is changed to “Third-Party Administrator (TPA).”
In the Fraud Statement section, the following is added as a second paragraph:
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or worker, insurance company, or self-insured program, files a statement of medical bill containing any false or misleading information commits insurance fraud, punishable as provided in section 817.234, F.S.
In the first sentence of the second paragraph of the Carrier Responsibilities section, “in-state and out-of-state” is deleted.
The Health Care Provider Responsibilities section is revised to state:
A health care provider is required to meet their obligations under this Manual, regardless of any business arrangement with any entity under which medical bills are prepared, processed, or submitted to the carrier.
Reimbursement for services or procedures not listed in the Fee Schedule must be made according to an agreed upon contract price. Therefore, at the time of request for authorization, a health care provider should inform the carrier of any services or procedures that are not listed in the Fee Schedule.
In the first paragraph of the Prior Authorization of Services section, “or a self-insured employer” is deleted.
Page 7:
In the Billing New Procedure Codes Not Listed in the Fee Schedule section, the following paragraph is deleted:
At the time of request for authorization, a health care provider should inform the carrier of any anticipated services or procedures that are not listed in the fee schedule.
Page 8:
In the Carrier Use of Codes, Descriptors, and References section, the term “policies” is replaced with “guidelines” in the first paragraph.
The Notice of Privacy Practices section is deleted.
Page 9:
The Medical Records section and the Mandatory Disclosure section are deleted.
The Billing to Carriers section now reads:
When requested by the carrier it is the responsibility of all health care providers to furnish, without charge, the following documentation:
A complete report regarding the patient’s symptoms, findings, and plan of treatment pursuant to reporting requirements of Form DFS-F5-DWC-25 (DWC-25);
An operative or procedural report when a surgical procedure is performed;
A narrative report when a consultation or an independent medical examination is rendered; and
Copies of any additional medical records.
Failure of the health care provider to submit documentation requested by the carrier may result in the billed service(s) being disallowed, adjusted, or denied for payment.
The Copying Charges for Medical Records section now reads:
Any copying charges for medical records shall be paid pursuant to paragraph 440.13(4)(b), F.S.
The Disclosure to Injured Workers, Employers, and Carries section and the Injured Worker’s Requests section are deleted.
Page 10:
The Carrier’s Requests section is deleted.
Page 12:
The Codes with No MRAs section is modified to delete the second paragraph which stated: “At the time of request for authorization, a health care provider should inform the carrier of any anticipated services or procedures that do not have MRAs according to this Manual.”
Page 19:
The Consultations section is modified to delete the last paragraph which stated: “The consultant’s opinion and any services that were ordered or performed must be communicated by written report to the requesting physician or other appropriate source.”
Page 22:
The following is added as the last paragraph of the Medications via Infusion Pumps section:
Manufacturer’s Shipping and Handling will be reimbursed at the actual cost on the invoice.
Page 23:
The Non-Reimbursable Drugs and Supplies section is amended to remove “the self-insured employer or.”
Page 24:
The Reimbursable Materials and Supplies section is amended to remove, “Circle the items on any invoice that are provided specifically to the injured worker.”
Page 364:
Reimbursement allowances for certain CPT codes were corrected to “NC.”
Page 370:
The Health Care Providers Who Bill on the DWC-9 section is amended to remove the second paragraph which stated: “At the time of request for authorization, a health care provider should inform the carrier of any anticipated services or procedures that are not listed in the fee schedule.”
Page 375:
Appendix C: Medicare Payment Localities was amended to add St. Lucie and Seminole counties to “Locality 01/Locality 02” and Indian River county was reformatted in “Locality 03.”
