The proposed rules represent a substantial rewrite and reorganization of Rule 69L-7.710, F.A.C., titled, “Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.” Existing Rule 69L-7.710, F.A.C., is rewritten and ...

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Worker’s Compensation

RULE NOS.:RULE TITLES:

69L-7.710Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule

69L-7.720Forms Incorporated by Reference for Medical Billing, Filing and Reporting

69L-7.730Health Care Provider Medical Billing and Reporting Responsibilities

69L-7.740Insurer Authorization and Medical Bill Review Responsibilities

69L-7.750Insurer Electronic Medical Report Filing to the Division

PURPOSE AND EFFECT: The proposed rules represent a substantial rewrite and reorganization of Rule 69L-7.710, F.A.C., titled, “Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.” Existing Rule 69L-7.710, F.A.C., is rewritten and reorganized into five proposed rules that are intended to replace existing Rule 69L-7.710, F.A.C. The proposed rules incorporate an updated version of Form DFS-F5-DWC-9, which includes revised instructions for the billing of medications by dispensing practitioners and revised instructions for pharmacists when billing on Form DFS-F5-DWC-10. The proposed rules also incorporate revised form completion instructions for pharmacies and pharmacists, hospitals, ambulatory surgical centers, health care providers, work hardening programs, nursing homes and home health agencies. The proposed rules add, revise and delete certain definitions consistent with the implementation of SB 662, Chapter 2013-131, Laws of Florida and, upon federal implementation, the use of the ICD-10 International Classification of Diseases (10th Revision). The proposed rules omit subsection 69L-7.710(3), entitled, “Materials Incorporated by Reference,” which is to be transferred for listing under proposed new Rule Chapter 69L-8, F.A.C., titled, “Selected Materials Incorporated by Reference.”

SUMMARY: The proposed rulemaking represents a substantial rewrite and reorganization of existing Rule 69L-7.710, F.A.C., which is divided into five rule sections. The rulemaking also incorporates and adopts the ICD-10 medical code sets for use in conjunction with the Florida Medical EDI Implementation Guide (“MEIG”). The proposed rules also include revised billing forms and accompanying instructions.

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: The Department has conducted an economic analysis of the proposed rules and determined that there are no adverse impacts or potential regulatory cost associated with any of the proposed rules that exceed the criteria established under paragraphs 120.541(1)(b) or 120.541(2)(a), F.S. The Department bases its economic analysis on its experience in estimating regulatory and transactional costs within the rulemaking process and through survey and consultation with affected entities and industry representatives.

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(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS.

LAW IMPLEMENTED: 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 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: Tuesday, June 2, 2015, 9:30 a.m.

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

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: Pamela Macon, [phone] or [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: Pamela Macon, Chief, Bureau of Monitoring and Audit, Division of Workers’ Compensation, Department of Financial Services, 200 E. Gaines Street, Tallahassee, Florida 32399-4232, [phone], [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

Substantial rewording of Rule 69L-7.710 follows. See Florida Administrative Code for present text.

69L-7.710 Definitions.

(1) As used in this Chapter:

(a) “Accurately Complete” or “Accurately Completed” means the form submitted contains the information necessary to meet the requirements of Chapter 440, F.S., and this rule.

(b) “Adjust” or “Adjusted” means payment is made with modification to the information provided on the bill.

(c) “Ambulatory Surgical Center” or “ASC” is defined in subsection 395.002(3), F.S.

(d) “Average Wholesale Price” or “AWP” is as defined in paragraph 440.13(12)(c), F.S., for medications dispensed on or after July 1, 2013.

(e) “Billing” means the process by which a health care provider submits a medical claim form or medical bill to an insurer, claim administrator or any entity acting on behalf of the insurer, to receive reimbursement for medical services, goods or supplies provided to an injured employee.

(f) “Catastrophic Event” means the occurrence of an event outside the control of a claim administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster or an act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent a claim administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and this rule. Programming errors, system malfunctions or electronic data interchange transmission failures that are not a direct result of a catastrophic event are not considered to be a catastrophic event as defined in this rule. See subsection 69L-7.750(4), F.A.C., for requirements to request approval of an alternative method and timeline for medical report filing with the Division due to a catastrophic event.

(g) “Charges” means the dollar amount billed.

(h) “Charge Master” means for hospitals a comprehensive listing of all the goods and services for which the facility maintains a separate charge, with the facility’s charge for each of the goods and services, regardless of payer type and means; for ASCs a listing of the gross charge for each CPT procedure for which an ASC maintains a separate charge, with the ASC’s charge for each CPT procedure, regardless of payer type.

(i) “Claim Administrator” means any insurer, qualified servicing entity, third party administrator, claims-handling entity, self-serviced self-insured employer or fund, guarantee fund, or managing general agent responsible for adjusting workers’ compensation claims.

(j) “Claim Administrator Code Number” means the number the Division assigns to an Insurer, qualified servicing entity, third party administrator, claims-handling entity, self-serviced self-insured employer or fund, guarantee fund, or managing general agent responsible for adjusting workers’ compensation claims.

(k) “Claim Administrator File Number” means the number assigned to the claim file by the claim administrator for purposes of internal tracking.

(l) “Current Dental Terminology” (CDT) means the American Dental Association’s reference document containing descriptive terms to identify codes for billing and reporting dental procedures, as incorporated by reference in Rule 69L-8.074, F.A.C.

(m) “Current Procedural Terminology” (CPT) means the American Medical Association’s reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services, as incorporated by reference in Rule 69L-8.074, F.A.C.

(n) “Date Insurer Paid Bill” and “Date Insurer Paid, Adjusted, Disallowed or Denied” means the date the claim administrator 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 Bill” and “Date Insurer Paid, Adjusted, Disallowed or Denied” means the date the claim 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 subsection 69L-7.750(8), F.A.C., for the requirement to accurately report the “Date Insurer Paid Bill.”

(o) “Date Insurer Received Bill” 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 of the claim administrator or any entity acting on behalf of the insurer. See subsection 69L-7.750(8), F.A.C., for the requirement to accurately report the “Date Insurer Received Bill”. If a medical bill meets any of the criteria in paragraph 69L-7.740(11)(g), F.A.C., and possession of the form is relinquished by the claim administrator or any entity acting on behalf of the insurer by returning the medical bill to the provider with a written explanation for the insurer’s reason for return, then “Date Insurer Received Bill” shall not apply to the medical bill as submitted.

(p) “Days” means calendar days unless otherwise noted.

(q) “Deny” or “Denied” means payment is not made because the service rendered is for treatment of a non-compensable injury or illness.

(r) “Department” means Department of Financial Services (DFS) as defined in subsection 440.02(12), F.S.

(s) “Disallow” or “Disallowed” means payment for a compensable injury or illness is not made because the service rendered has not been substantiated for reasons of medical necessity, insufficient documentation, lack of authorization or billing error.

(t) “Division” means the Division of Workers’ Compensation (DWC) as defined in subsection 440.02(14), F.S.

(u) “Electronic Filing” means the computer exchange of medical data from a sender to the Division in the standardized format defined in the MEIG.

(v) “Electronic Form Equivalent” means the record, provided in the Florida Medical EDI Implementation Guide MEIG to be used when a sender electronically transmits required data to the Division. Electronic form equivalents do not include transmission by facsimile, data file(s) attached to electronic mail, or computer-generated paper-forms.

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

(x) “Entity” means any party involved in the processing, adjudication or payment of medical bills on behalf of the insurer.

(y) “Explanation of Bill Review” (EOBR) means the document used to provide notice of payment or notice of adjustment, disallowance or denial by a claim administrator or any entity acting on behalf of an insurer to a health care provider containing code(s) and code descriptor(s), in conformance with subsection 69L-7.740(13), F.A.C.

(z) “Explanation of Bill Review Code” (EOBR Code) means a code listed in paragraph 69L-7.740(13)(b), F.A.C., that describes the basis for the reimbursement decision of a claim administrator or any entity acting on behalf of the insurer.

(aa) “Florida Medical EDI Implementation Guide” (MEIG) is the Division’s reference document containing the specific electronic formats, data elements, and requirements for insurer reporting of medical data to the Division, as incorporated by reference in Rule 69L-8.074, F.A.C.

(bb) “Healthcare Common Procedure Coding System National Level II Codes” (HCPCS) means the Centers for Medicare and Medicaid Services’ reference document listing descriptive codes for billing and reporting professional services, procedures, and supplies provided by health care providers, as incorporated by reference in Rule 69L-8.074, F.A.C.

(cc) “Health Care Provider” is defined in paragraph 440.13(1)(g), F.S.

(dd) “Home Health Agency” (HHA) is defined in subsection 400.462(12), F.S.

(ee) “Home Medical Equipment Provider,” sometimes referred to as durable medical equipment or DME provider, is defined in subsection 400.925(7), F.S.

(ff) “Hospital” is defined in subsection 395.002(12), F.S.

(gg) “ICD-9-CM International Classification of Diseases” (ICD-9) is the U.S. Department of Health and Human Services’ reference document listing the official diagnosis and inpatient procedure code sets, as incorporated by reference in Rule 69L-8.074, F.A.C.

(hh) “ICD-10 International Classification of Diseases” (ICD-10) is the 10th Revision of the International Classification of Diseases set of diagnosis and inpatient procedure codes, as incorporated by reference in Rule 69L-8.074, F.A.C.

(ii) “Implants” means the surgical implant(s), the associated disposable instrumentation required for use with the surgical implant(s) and the shipping and handling, when listed on the implant invoice.

(jj) “Insurer” is defined in subsection 440.02(38), F.S.

(kk) “Insurer Code Number” means the number the Division assigns to each individual insurer, self-insured employer, self-insured fund, or guaranty fund financially responsible for the claim.

(ll) “Itemized Statement” means a detailed listing of goods, services and supplies provided to an injured employee, including the quantity and charges for each good, service or supply.

(mm) “Medical Bill” means the document or electronic form equivalent submitted by a health care provider to an Insurer, Service Company/Third Party Administrator or any entity acting on behalf of the Insurer for reimbursement for services or supplies (e.g., DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider’s usual invoice or business letterhead) as appropriate pursuant to Rule 69L-7.730(2), F.A.C.

(nn) “Medically Necessary” or “Medical Necessity” is defined in paragraph 440.13(1)(k), F.S.

(oo) “NDC Number” means the eleven-digit National Drug Code (NDC) number, assigned under Section 510 of the Federal Food, Drug, and Cosmetic Act, which identifies the drug product labeler/vendor, product, and trade package size. As used in this Rule Chapter, when referring to dispensed drugs, “Original Manufacturer’s NDC Number” shall mean the NDC Number assigned by the original manufacturer of the underlying dispensed drug; and, “Repackaged NDC Number” shall mean the NDC Number assigned by the repackager/relabeler of the underlying dispensed drug.    

(pp) “Nursing Home Facility” is defined in subsection 400.021(12), F.S.

(qq) “Pay” or “Paid” means payment is made applying the applicable reimbursement formula to the medical bill as submitted.

(rr) “Physician” is defined in paragraph 440.13(1)(p), F.S.

(ss) “Primary Physician” means the treating physician responsible for the oversight of medical care, treatment and attendance rendered to an injured employee, to include recommendation for appropriate consultations or referrals.

(tt) “Recognized Practitioner” means a non-physician health care provider licensed by the Department of Health who works under the protocol of a physician or who, upon referral from a physician, can render direct billable services that are within the scope of the recognized practitioner’s license, independent of the supervision of a Physician.

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

(vv) “Service Company/Third Party Administrator (TPA)” means an entity that has contracted with an insurer for the purpose of providing services necessary to adjust workers’ compensation claims on the Insurer’s behalf.

(ww) “Sender” means an Insurer, Service Company/TPA, entity or any other party acting on behalf of an Insurer, Service Company/TPA or any entity to fulfill any Insurer responsibility to electronically transmit required medical data to the Division.

(xx) “UB-04 Manual” means the National Uniform Billing Committee Official UB-04 Data Specifications Manual, which is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2015), as incorporated by reference in Rule 69L-8.074, F.A.C.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06, 3-8-07, 1-12-10, 10-23-12, Formerly 69L-7.602, Amended            . 

 

69L-7.720 Forms Incorporated by Reference for Medical Billing, Filing and Reporting.

(1) The following forms, including form completion instructions, are incorporated for use with rules adopted under this Rule Chapter.

(a) Form DFS-F5-DWC-9 CMS-1500 Health Insurance Claim Form, Rev. 02/12,

Completion Instructions for the DFS-F5-DWC-9 are comprised of three sets.

1. Form DFS-F5-DWC-9-A, Completion Instructions for Physicians and Recognized Practitioners, Rev. 01/01/2015;

2. Form DFS-F5-DWC-9-B, Completion Instructions for Work Hardening and Pain Management Programs, Rev. 01/01/2015;

3. Form DFS-F5-DWC-9-C, Completion Instructions for  Ambulatory Surgical Centers, Rev. 01/01/2015 (only for dates of services prior to July 8, 2010);

(b) Form DFS-F5-DWC-10, Statement of Charges for Drugs and Medical Equipment & Supplies Form, Rev. 01/01/2015, Form DFS-F5-DWC-10-A, Completion Instructions for Pharmacies And Home Medical Equipment Providers/Suppliers, Rev. 01/01/2015;

(c) Form DFS-F5-DWC-11, American Dental Association Dental Claim Form, Rev. 2012; Form DFS-F5-

DWC-11-A Completion Instructions for Dentists, Rev. 01/01/2015;

(d) Form DFS-F5-DWC-25, Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form, Rev. 1/31/2008, Form DFS-F5-DWC-25-A, Completion Instructions for Physicians and Recognized Practitioners, Rev. 01/01/2015.

(e) Form DFS-F5-DWC-90 (UB-04/CMS-1450), Uniform Bill, Rev. 11/03/2006; Completion Instructions for the DFS-F5-DWC-90 are comprised of four sets:

1. Form DFS-F5-DWC-90-A (UB-04), Completion Instructions for Hospitals, Rev. 01/01/2015;

2. Form DFS-F5-DWC-90-B (UB-04), Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (for dates of service on and after 07/08/2010);

3. Form DFS-F5-DWC-90-C (UB-04), Completion Instructions for Home Health Agencies, Rev. 01/01/2015;

4. DFS-F5-DWC-90-D (UB-04), Completion Instructions for Nursing Home Facilities, Rev. 01/01/2015.

(2) Obtaining Copies of Forms and Instructions.

(a) A copy of the Form DFS-F5-DWC-9 can be obtained from the AMA web site: https://commerce.ama-assn.org/store/. Completion instructions for the DFS-F5-DWC-9 can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) web site:

http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.

htm.

(b) A copy of the Form DFS-F5-DWC-10 and completion instructions for the form can be obtained from the DFS/DWC website: http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.

htm.

(c) A copy of the Form DFS-F5-DWC-11 can be obtained from the American Dental Association web site: http://www.ada.org/. Completion instructions for the form can be obtained from the DFS/DWC web site: http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(d) A copy of the Form DFS-F5-DWC-25 and completion instructions can be obtained from the DFS/DWC web site: http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.

htm.

(e) A copy of the instructions for completion of Form DFS-F5-DWC-90 (Rev. 2006), Form DFS-F5-DWC-90 (UB-04)-A (for Hospitals) (Rev. 01/01/2015), Form DFS-F5-DWC-90 (UB-04)-B (for ASCs) (Rev. 01/01/2015), Form DFS-F5-DWC-90 (UB-04)-C (for Home Health Agencies) (Rev. 01/01/2015), Form DFS-F5-DWC-90 (UB-04)-D (for Nursing Home Facilities), (Rev. 01/01/2015), can be obtained from the DFS/DWC web site: http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(3) Alternate Billing Forms for Use in Lieu of DFS-F5-DWC-10.

In lieu of submitting a Form DFS-F5-DWC-10, when billing for drugs or medical supplies, alternate billing forms are acceptable if:

(a) An insurer has approved the alternate billing form(s) prior to submission by a health care provider, and

(b) The form provides all information required to be submitted to the Division, pursuant to the MEIG, on the Form DFS-F5-DWC-10. Form DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form for the DFS-F5-DWC-10.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New______. Editorial Note: Formerly 69L-7.602 and 69L-7.710, F.A.C.

 

69L-7.730 Health Care Provider Medical Billing and Reporting Responsibilities.

(1) Bill Submission/Filing and Reporting Requirements.

(a) All health care providers are responsible for meeting their obligations, under this rule, regardless of any business arrangement with any entity under which claims are prepared, processed or submitted to the insurer.

(b) Each health care provider is responsible for submitting any form completion information and supporting documentation requested by the insurer that is in addition to the requirements of this rule and the applicable reimbursement manual, when it is requested, in writing, by the insurer at the time of authorization or upon receipt of notification of emergency care.

(c) Each health care provider shall resubmit a medical claim form or medical bill with insurer-requested documentation when the EOBR provides an explanation for the disallowed service based on the provider’s failure to submit requested documentation with the medical bill.

(d) 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. No other reporting forms may be used in lieu of or supplemental to the Form DFS-F5-DWC-25.

1.The Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.

2. All information submitted on physician notes, medical records or Division-required medical reports shall be consistent with information documented on the Form DFS-F5-DWC-25.

3. The DFS-F5-DWC-25, submitted to address the physical limitation(s), permanent impairment rating or maximum medical improvement date, shall be signed by the physician performing the physical examination upon which the physical limitation(s), permanent impairment or maximum medical improvement date is based.

(e) All medical claim form(s) or medical bill(s) related to authorized services shall be coded by the health care provider at the highest level of specificity and submitted to the claim administrator or any entity acting on behalf of the insurer, as a requirement for billing.

(f) Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the claim administrator or any entity acting on behalf of the insurer, provided the insurer agrees.

(g) When requested by the claim administrator or any entity acting on behalf of the insurer, a health care provider shall send documentation that supports the medical necessity of the specific services rendered and any other required documentation pursuant to subsection 69L-7.730(2), F.A.C., and the applicable reimbursement manual.

(h) Each health care provider is responsible for correcting and resubmitting any billing forms returned by a claim administrator or any entity acting on behalf of the insurer pursuant to paragraph 69L-7.740(11)(g), F.A.C.

(i) Each hospital and ASC shall maintain its charge master and shall produce relevant portions when requested for the purpose of verifying its usual charges pursuant to paragraph 440.13(12)(d), F.S.

(j) A health care provider shall bill multiple services, rendered on the same date of service, on a contiguous bill; provided however, nothing herein shall prevent a physician from selling, assigning or otherwise factoring a claim for the provision of pharmacy related services to a third party billing entity.

(2) Special Billing Requirements.

(a) When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form shall include the CPT® code and the “P” code (physical status modifier), which correspond with the procedure performed, in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code, which correspond with the procedure performed, in Field 24D on the next line, if applicable.

(b) When a certified registered nurse anesthetist provides anesthesia services, the individual shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter their Florida Department of Health Advanced Registered Nurse Practitioner license number in Field 33b, regardless of the employment arrangement under which the services were rendered, or the party submitting the bill.

(c) Recognized practitioners, except physician assistants, advanced registered nurse practitioners, certified registered nurse anesthetists, who are salaried employees of an authorized treating physician and who render direct billable services for which reimbursement is sought from a claim administrator or any entity acting on behalf of the claim administrator shall report and bill for such services on a Form DFS-F5-DWC-9 under the employing physician’s name and license number.

(d) For hospital billing, the following special requirements apply:

1. Inpatient billing – Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:

a. Attach an itemized statement with charges based on the facility’s charge master; and

b. Submit all specifically requested and additional documentation requested at the time of authorization; and

c. Bill professional services provided by a physician, physician assistant, advanced registered nurse practitioner, or registered nurse first assistant on the Form DFS-F5-DWC-9, regardless of employment arrangement; and

d. In Form Locator 80 - “Remarks”- make written entry “implant(s)” followed by the certification amount or the reimbursement amount calculated pursuant to Rule 69L-7.501, F.A.C.

2. Outpatient billing – Hospitals shall in addition to filing a Form DFS-F5-DWC-90:

a. Enter the CPT®, HCPCS or workers’ compensation unique code and the applicable CPT® or HCPCS modifier code in Form Locator 44 on the Form DFS-F5-DWC-90, when required pursuant to the UB-04 Manual; and

b. Make written entry “scheduled” or “non-scheduled” in Form Locator 80 of Form DFS-F5-DWC-90 – “Remarks” on the DFS-F5-DWC-90 when billing outpatient surgery or outpatient surgical services; and

c. Attach an itemized statement with charges based on the facility’s charge master; and

d. Submit all applicable documentation required pursuant to Rule 69L-7.501, F.A.C.; and

e. Bill professional services provided by a physician or recognized practitioner on the Form DFS-F5-DWC-9, regardless of employment arrangement.

(e) A certified, licensed physician assistant and registered nurse first assistant who provides services as a surgical assistant, in lieu of a second 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 shall enter the individual’s Florida Department of Health license number in Field 33b.

(f) ASCs shall bill as follows:

1. For dates of service up to and including 07/07/2010, ASCs shall bill on Form DFS-F5-DWC-9 using the American Medical Association’s CPT® procedure codes, or using the workers’ compensation unique procedure code 99070 with required modifiers, and shall bill charges based on the ASC’s charge master except when billing for procedure code 99070.

2. For dates of service on and after 07/08/2010, ASCs shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS, or workers’ compensation unique code and the applicable CPT® or HCPCS modifier code in Form Locator 44 for each service rendered.  ASCs shall bill charges based on the ASC’s charge master except when billing for surgical implants, associated disposable instrumentation and applicable shipping and handling. ASCs shall use revenue center code 0278 and workers’ compensation unique code(s) with required modifier(s), as defined in the MEIG and pursuant to Rule 69L-7.100, F.A.C., when billing for surgical implants, associated disposable instrumentation, and applicable shipping and handling pursuant to Rule 69L-7.100, F.A.C. ASC medical bills shall be accompanied by all applicable documentation or certification required pursuant to Rule 69L-7.100, F.A.C.

(g) HHAs shall bill on Form DFS-F5-DWC-90.

1. For dates of service up to and including 07/07/2010, HHAs shall bill on letterhead or invoice.

2. For dates of service on or after 07/08/2010, HHAs shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation unique codes and the applicable CPT® or HCPCS modifier code in Form Locator 44 for each service rendered.

(h) Nursing home facilities shall bill on Form DFS-F5-DWC-90.

1. For dates of service up to and including 07/07/2010, nursing home facilities shall bill on letterhead or invoice.

2. For dates of service on or after 07/08/2010, nursing home facilities shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation unique code and the applicable CPT® or HCPCS modifier code in Form Locator 44 for each service rendered.

(i) Federal facilities shall bill on their usual form.

(j) Out-of-state health care providers shall bill on the applicable medical bill form pursuant to subsection 69L-7.730(3), F.A.C.

(k) Dental services.

1. Dentists shall bill for services on Form DFS-F5-DWC-11.

2. Oral surgeons shall bill for oral and maxillofacial surgical services on a Form DFS-F5-DWC-9. Non-surgical dental services shall be billed on Form DFS-F5-DWC-11.

(l) Pharmaceutical(s), DME and home medical equipment or supplies.

1. When dispensing commercially available medicinal drugs commonly known as legend or prescription drugs:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit original manufacturer’s NDC number in Field 9a. When the dispensed drug is a repackaged/relabeled drug, the provider shall, in addition to the above, enter the repackaged NDC number in Field 9b of Form DFS-F5-DWC-10.

b. Physicians (including oral surgeons), physician assistants, advanced registered nurse practitioners, and any other recognized practitioner registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form DFS-F5-DWC-9. Subsection 440.13(12)(c), F.S, requires the original manufacturer’s NDC number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

d. Dentists registered to dispense medications pursuant to Section 465.0276, F.S., shall bill on Form-DFS-F5-DWC-11. Paragraph 440.13(12)(c), F.S., requires the original manufacturer’s NDC number to be included in the claim when repackaged or re-labeled medications have been dispensed. See the DFS-F5-DWC-11 Form Completion Instructions in Rule 69L-7.720, F.A.C.

2. When dispensing medicinal drugs which are compounded and the prescribed formulation is not commercially available:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the workers’ compensation unique code COMPD, as defined in the MEIG, in Field 9a.

b. Physicians, physician assistants or advanced registered nurse practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the workers’ compensation unique code COMPD, as defined in the MEIG, in Field 24D.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

3. When dispensing over-the-counter drug products:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit NDC number in form Field 9a.

b. Physicians (including oral surgeons), physician assistants or advanced registered nurse practitioners shall bill on Form DFS-F5-DWC-9, shall enter the 11 digit NDC number in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

4. When administering or dispensing injectable drugs:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the 11 digit NDC number in Field 9a.

b. Physicians, physician assistants or advanced registered nurse practitioners shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field 24D. When an appropriate HCPCS “J” code is not available for the injectable drug, enter the 11 digit NDC number, preceded by the alpha-numeric qualifier (N4), in the shaded portion above Field 24. See the DFS-F5-DWC-9 Form Completion Instructions in Rule 69L-7.720, F.A.C.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.

5. When dispensing DME:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

b. Physicians and recognized practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the applicable HCPCS code in Field 24D of the form and attach documentation indicating the actual cost of the supply.

c. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable revenue codes.

d. Home medical equipment providers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

6. When dispensing medical supplies which are not incidental to a service or procedure:

a. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

b. Physicians and recognized practitioners shall bill on Form DFS-F5-DWC-9 and shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply.

c. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable revenue codes.

d. Home medical equipment providers shall bill on Form DFS-F5-DWC-10 for DME supplies prescribed by a physician or recognized practitioner, and shall enter the applicable HCPCS code in Field 21 on Form DFS-F5-DWC-10.

7. Pharmacists who provide medication therapy management services shall bill for these services on Form DFS-F5-DWC-9 by entering the appropriate CPT® code(s) that represent the service(s) rendered in form Field 24D, shall enter their Florida Department of Health license number in Field 33b and shall submit a copy of the physician’s written prescription with the medical bill.

8. Pharmacists and medical suppliers may only bill on an alternate to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be approved for use as the alternate form.

(m) Physicians billing for a failed appointment for a scheduled independent medical examination (when the injured employee does not report to the physician office as scheduled) shall bill worker’s compensation unique code 99456-CN on the DFS-F5-DWC-9.

(n) Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) shall accurately complete the Form DFS-F5-DWC-9 and submit the form to the insurer.

(o) Parties that are not physicians or recognized practitioners but are authorized by an insurer to render services reimbursable under workers’ compensation shall bill on their invoice or letterhead. These parties shall not bill using Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.

(p) Only a physician as defined in paragraph 440.13(1)(p), F.S., can bill workers’ compensation unique codes 99455, 99456, 99457 when reporting services to address maximum medical improvement and permanent impairment.

(3) Bill Completion.

(a) Bills shall be legibly and accurately completed by all health care providers, regardless of location or reimbursement methodology, as set forth in this subpart and in subsection 69L-7.730(2), F.A.C.

(b) Billing elements required by the Division to be completed by a health care provider are identified in Form DFS-F5-DWC-9-B Completion Instructions, Rev. 01/01/2015, and are available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/pdf/DWC-9instrHCP.pdf, when submitted by licensed health care providers;

2. http://www.myfloridacfo.com/Division/WC/provider/DWC-9instrWHPM.pdf, when submitted by work hardening and pain management programs.

3. http://www.myfloridacfo.com/Division/WC/provider/DWC-9instrASC.pdf, when submitted by an ASC for dates of service before 07/08/2010.

(c) Billing elements required by the Division to be completed for pharmaceutical or medical supplier billing are identified in Form DFS-F5-DWC-10 Completion Instructions, Rev.1/01/2015, are available at the following website: http://www.myfloridacfo.com/Division/WC/pdf/DFS-F2-DWC-10instr.pdf.

(d) Billing elements required by the Division to be completed for dental billing are identified in Form DFS-F5-DWC-11-B Completion Instructions, Rev.01/01/2015, are available at website: http://www.myfloridacfo.com/Division/WC/provider/DWC-11instr_1-1-07.pdf.

(e) Billing elements required by the Division to be completed by facilities are identified in Form DFS-F5-DWC-90 (UB-04) Completion Instructions, Rev. 01/01/15, and are available at the following websites:

1. http://www.myfloridacfo.com/Division/WC/provider/DWC-90(UB-04)-A  (Rev. 01/01/2015), when submitted by a hospital.

2. http://www.myfloridacfo.com/Division/WC/provider/DWC-90 (UB-04)-B (Rev. 01/01/2015), when submitted by an ASC for dates of service on or after 7/8/2010.

3. http://www.myfloridacfo.com/Division/WC/provider/DWC-90 (UB-04)-C (Rev. 01/01/2015), when billed by a HHA.

4. http://www.myfloridacfo.com/Division/WC/provider/DWC-90(UB-04) –D, (Rev. 01/01/2015), when billed by a nursing home facility.

(f) A health care provider shall submit additional data elements or supporting documentation required for the adjudication of a bill upon receipt of a written request from the insurer/claim administrator pursuant to subsection 69L-7.740(2), F.A.C.

(g) A health care provider may bill consistent with the requirements of ICD-10 beginning on the implementation date specified for use of ICD-10 in section 62.1002 of Title 45 of the Code of Federal Regulations.  Under no circumstance may a health care provider utilize both ICD-9 and ICD-10 coding on the same bill.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New _______. Editorial Note: Formerly 69L-7.602 and 69L-7.710, F.A.C.

 

69L-7.740 Insurer Authorization and Medical Bill Review Responsibilities.

(1) An insurer is responsible for meeting its obligations under this rule regardless of any business arrangements with any claim administrator or any entity acting on behalf of an insurer under which medical bills are paid, adjusted, disallowed, denied, or otherwise processed or submitted to the Division.

(2)(a)  At the time of authorization for medical service(s) or upon receipt of notification of emergency care, an insurer shall notify each health care provider, in writing, of data elements or supporting documentation necessary for reimbursement determinations that are in addition to the requirements of this rule and the applicable reimbursement manual.

(b) This subpart applies to dates of injury occurring on or after October 1, 2003. At the time of authorization for medical service(s), or upon receipt of notification of emergency care, an insurer shall issue a written or electronic notice to each health care provider stating whether the insurer will, when paying reimbursement for the medical service(s) for a compensable injury, apportion out the percentage of need for the care attributable to a pre-existing condition pursuant to subsection 440.15(5), F.S. If the insurer decides to apportion out the percentage of need for the care attributable to the pre-existing condition after authorization, the insurer shall issue a written or electronic notice to each health care provider stating that the insurer will apply such apportionment, pursuant to subsection 440.15(5), F.S., to the reimbursement for the authorized medical service(s). Compliance with this subpart is independent of and does not satisfy the notification requirement pursuant to Rule 69L-3.017, F.A.C.

(3) At the time of authorization for medical service(s), or upon receipt of notification of emergency care, an insurer shall inform out-of-state health care providers of the specific reporting, billing and submission requirements contained in Rule 69L-7.730, F.A.C. (Health Care Provider Responsibilities), and provide in-state and out-of-state health care providers the specific address for submitting a reimbursement request.

(4) Claim administrators 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 and for requesting approval of a treatment plan. No other reporting forms may be used in lieu of or supplemental to the Form DFS-F5-DWC-25.

(5) Required data elements on each electronic form equivalent of Form 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 Division within 45 days of when the medical bill is paid, adjusted, disallowed or denied by the insurer, claim administrator or any entity acting on behalf of the insurer. The 45 day filing requirement includes initial submission and correction and re-submission of all errors identified in the “Medical Bill Acknowledgement,” as defined in the MEIG.

(6) An Insurer shall be responsible for accurately completing required data filed with the Division, pursuant to the MEIG and Rule 69L-7.750, F.A.C. Additionally, an insurer or entity acting on behalf of an insurer shall be responsible for correcting previously accepted data that is deemed inaccurate by the Division through monitoring, auditing, investigation or analysis, and resubmitting the corrected and accurate data in accordance with the requirements set forth in the MEIG and subsection 69L-7.750(5), F.A.C.

(7) When an injured employee does not have a social security number or a previously assigned division-assigned number, the claim administrator or entity acting on behalf of the insurer shall contact the Division via email at [e-mail] to obtain a division-assigned number prior to submitting the medical report to the Division.

(8) An insurer, claim administrator or any entity acting on behalf of an insurer shall report to the Division the procedure code(s), number of line-items billed, diagnosis code(s), modifier code(s), NDC number(s) and amount(s) charged, as billed by the health care provider when reporting these data to the Division. However, the insurer, claim administrator or any entity acting on behalf of an insurer may correct the procedure code(s) or modifier code(s) or NDC number(s) to effect payment and shall report both the provider billed code(s) and insurer adjusted code(s) pursuant to the MEIG. The insurer, claim administrator or any entity acting on behalf of an insurer shall utilize the EOBR code “80” to notify the health care provider concerning any such billing errors and shall transmit EOBR code “80”, in instances when the carrier corrects the provider coding, when reporting to the Division.

(9) An insurer, claim administrator 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 the electronic form equivalent on the “Date Insurer Received Bill” as defined in paragraph 69L-7.710(1)(o), F.A.C.

(10) When utilizing the option(s) available under paragraph 69L-7.750(8)(a), F.A.C., the insurer shall document the following:

(a) The option(s) selected, and

(b) The specific effective date for each option selected, and

(c) The specific role of each “entity” acting on the insurers behalf in the option selected.

The insurer shall make this written documentation available to the Division for audit purposes pursuant to Section 440.525, F.S. The insurer shall maintain written documentation from the “entity” acknowledging its responsibilities concerning “Date Insurer Received Bill” and “Date Insurer Paid Bill” for each option when the insurer selects options 2., 3., or 4. from paragraph 69L-7.750(8)(a), F.A.C., and shall also maintain written documentation identifying the applicability of the options selected in sufficient detail to allow verification of the coding of each medical bill under paragraph 69L-7.750(8)(c), F.A.C.

(11) An insurer, claim administrator or any entity acting on behalf of the insurer shall comply as indicated below to ensure the timely and correct reimbursement of properly completed medical bills:

(a) When adjudicating practitioner-dispensed medication bills, an insurer/claim administrator or any entity acting on behalf of an insurer shall use the Medi-Span Master Drug Database®, pursuant to paragraph 440.13(12)(c), F.S., to determine whether or not the dispensed medication is repackaged.

(b) When a medical bill is submitted for reimbursement by a health care provider, the insurer, claim administrator or entity acting on behalf of the insurer shall review the medical bill to determine if any of the criteria in paragraph 69L-7.740(11)(e), F.A.C., are present.

(c) If a medical bill is deficient according to the criteria listed in paragraph 69L-7.740(11)(g), F.A.C., and the applicable form completion instructions incorporated by reference in Rule 69L-7.720, F.A.C., the insurer, claim administrator or entity acting on behalf of the insurer shall either:

1. Secure and/or correct the information on the medical bill and proceed to make a reimbursement decision to pay, adjust, disallow or deny billed charges within 45 days from the “Date Insurer Received Bill”; or

2. Return the medical bill to the provider within twenty-one (21) days of the “Date Insurer Received Bill” with a written statement identifying the deficiency criteria under which the medical bill is being returned. The written statement sent to the provider with the returned medical bill shall bear the following statement CAPITALIZED and in BOLD print: “A HEALTH CARE PROVIDER MAY NOT BILL THE INJURED EMPLOYEE FOR SERVICES RENDERED FOR A COMPENSABLE WORK-RELATED INJURY.”

(d) If the insurer returns a medical bill to the provider pursuant to paragraph 69L-7.740(11)(g), F.A.C., the written statement, which shall accompany the returned bill shall include all deficiency criteria upon which the return of the medical bill are based.

(e) If the deficiency criteria upon which the return of the medical bill is based includes any of the deficiency criteria in subparagrahs 69L-7.740(11)(g)4-7, F.A.C., and the applicable form completion instructions, the written statement shall identify the information that is illegible, incorrect, or omitted.

(f) An insurer may return a medical bill to a provider without issuance of an EOBR only on the basis of the deficiency criteria set forth in paragraph 69L-7.740(11)(e), F.A.C., and the applicable form completion instructions.

(g) The deficiency criteria upon which a medical bill is to be reviewed by the insurer, claim administrator or entity acting on behalf of the insurer for return to the provider pursuant to this sub-part of subsection 69L-7.740(11), F.A.C., are:

1. Services are billed on an incorrect medical billing form; or

2. The medical bill has been submitted to the incorrect insurer; or

3. The medical bill has been submitted to the incorrect claim administrator or entity acting on behalf of the insurer; or

4. Injured employee identification information required by this rule and the applicable form completion instructions is illegible on the medical bill; or

5. Injured employee identification information required by this rule and the applicable form completion instructions is incorrect on the medical bill; or

6. Billing information required by this rule and the applicable form completion instructions is illegible on the medical bill; or

7. Billing information required by this rule and the applicable form completion instructions is omitted or incomplete on the medical bill.

(h) An insurer, claim administrator or entity acting on behalf of the insurer shall establish and maintain a process by which medical bills that have been returned and written statements identifying the reason for return are compiled. The compiled information shall be sufficiently detailed to allow verification and review by the Division.

(12) A claim administrator or any entity acting on behalf of the insurer shall pay, adjust, disallow or deny billed charges within 45 days from the “Date Insurer Received Bill,” pursuant to paragraph 440.20(2)(b), F.S.

(13) In completing an EOBR, a claim administrator shall, for each line item billed, select the EOBR code(s) from the list below which identifies(y) the reason(s) for the reimbursement decision for each line item.

(a) The claim administrator may utilize up to three EOBR codes for each line item billed. When utilizing more than one EOBR code, the claim administrator shall list the EOBR codes that describe the basis for the claim administrator’s reimbursement decision in descending order of importance.

(b) The EOBR code list is as follows:

06 – Payment disallowed: location of service(s) is not appropriate for the level of service(s) billed.

10 – Payment denied: total denial: total compensability denied or the injury or illness for which service was rendered is not compensable.

11 - Payment denied: partial denial: diagnosis or procedure code for the line item service is not related to the compensable condition. (Insurer must specify the non-compensable condition).

21 – Payment disallowed: medical necessity: medical records reflect no physician’s order was given for service rendered or supply provided.

22 – Payment disallowed: medical necessity: medical records reflect no physician’s prescription was given for service rendered or supply provided.

23 – Payment disallowed: medical necessity: diagnosis does not support the service rendered.

24 – Payment disallowed: medical necessity: service rendered was not therapeutically appropriate.

25 – Payment disallowed: medical necessity: service rendered was experimental, investigative or research in nature.   

26 – Payment disallowed: service rendered by healthcare practitioner outside scope of practitioner’s licensure.

30 – Payment disallowed: lack of authorization: no authorization given for service rendered or notice provided for emergency treatment pursuant to subsection 440.13(3), F.S.

34 – Payment disallowed: no modification to the information provided on the medical bill. No payment made pursuant to contractual arrangement.

38 – Payment disallowed: insufficient documentation: documentation does not support this supply was dispensed to the patient.

39 – Payment disallowed: insufficient documentation: documentation does not support this medication was dispensed to the patient.

40 – Payment disallowed: insufficient documentation: documentation does not substantiate the service billed was rendered.

41 – Payment disallowed: insufficient documentation: level of evaluation and management service not supported by documentation. (Insurer shall specify missing components of evaluation and management code description.)

42 – Payment disallowed: insufficient documentation: intensity of physical medicine and rehabilitation service not supported by documentation.

43 – Payment disallowed: insufficient documentation: frequency of service not supported by documentation.

44 – Payment disallowed: insufficient documentation: duration of service not supported by documentation.

45 – Payment disallowed: insufficient documentation: fraud statement not provided pursuant to subsection 440.105(7), F.S.

46 – Payment disallowed: insufficient documentation: required itemized statement not submitted with the medical bill.

47 – Payment disallowed: insufficient documentation: invoice or certification not submitted for implant.

48 – Payment disallowed: insufficient documentation: invoice not submitted for supplies.

49 – Payment disallowed: insufficient documentation: invoice not submitted for medication.

50 – Payment disallowed: insufficient documentation: specific documentation requested in writing at the time of authorization not submitted with the medical bill. (Insurers shall specify omitted documentation.)

51 – Payment disallowed: insufficient documentation: required DFS-F5-DWC-25 not submitted.

52 – Payment disallowed: insufficient documentation: supply(ies) incidental to the procedure. (Incidental supply shall be specified.)

53 – Payment disallowed: insufficient documentation: required operative report not submitted with the medical bill.

54 – Payment disallowed: insufficient documentation: required narrative report not submitted with the medical bill.

58 – Payment disallowed: billing error: omitted or incorrect/invalid original manufacturer’s NDC number.

NOTE:    If a valid original manufacturer’s NDC number for prescription medication is billed alone, it should be reimbursed and reported under EOBR code 98.

59 - Payment disallowed: billing error: omitted or incorrect/invalid repackaged NDC number.

NOTE: If a valid original manufacturer’s NDC number for prescription medication is billed alone, it should be reimbursed and reported under EOBR code 98.

60 – Payment disallowed: billing error: line item service previously billed and reimbursement decision previously rendered.

NOTE: Use EOBR code 61 when all lines on bill are disallowed as duplicates. Do not transmit bill electronically to the Division.

61 – Payment disallowed: billing error: duplicate bill.

NOTE: Do not transmit bill electronically to the Division.

62 – Payment disallowed: billing error: incorrect procedure, modifier, units, supply code.

63 – Payment disallowed: billing error: service billed is integral component of another procedure code. (Shall specify inclusive procedure code).

64 – Payment disallowed: billing error: service “not reimbursable” under applicable workers’ compensation reimbursement manual.

65 – Payment disallowed: billing error: multiple providers billed on the same form.

66 – Payment disallowed: billing error: omitted procedure, modifier, units, or supply code.

67 – Payment disallowed: billing error: Same service billed multiple times on same date of service.

68 – Payment disallowed: billing error: Rental value has exceeded purchase price per written fee agreement.

71 – Payment adjusted: insufficient documentation: level of evaluation and management service not supported by documentation.

72 – Payment adjusted: insufficient documentation: intensity of physical medicine and rehabilitation service not supported by documentation.

73 – Payment adjusted: insufficient documentation: frequency of service not supported by documentation.

74 – Payment adjusted: insufficient documentation: duration of service not supported by documentation.

75 – Payment adjusted: insufficient documentation: specific documentation requested in writing at the time of authorization not submitted with the medical bill.

80 – Payment adjusted: billing error: correction of procedure, modifier, supply code, units, or original manufacturer’s NDC number (shall identify correction).

NOTE: Shall not be used with repackaged medications.

81 – Payment adjusted: billing error: payment modified pursuant to a charge audit.

83 – Payment adjusted: medical benefits paid apportioning out the percentage of the need for such care attributable to preexisting condition pursuant to paragraph 440.15(5)(b), F.S.

84 – Payment adjusted: co-payment applied pursuant to paragraph 440.13(13)(c), F.S.

85 – Payment adjusted: no modification to the information provided on the medical bill. Payment made pursuant to a fee agreement between the health care provider and the carrier.

      86- Payment adjusted: billing error; repackaged medication; correction of NDC number dispensed or reimbursed pursuant to paragraph 440.13(12)(c), F.S. (Insurer shall indicate the corrected  NDC number dispensed or reimbursed).

90 – Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers’ Compensation Health Care Provider Reimbursement Manual.

91 – Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers.

92 – Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers’ Compensation Reimbursement Manual for Hospitals.

93 – Paid: no modification to the information provided on the medical bill: payment made pursuant to written contractual arrangement (network or preferred provider organization name required).

94 – Paid: Out-of-state provider: payment made pursuant to the out-of-state provider section of the applicable Florida reimbursement manual.

95 – Paid: Reimbursement dispute resolution: payment made pursuant to receipt of a determination or final order on a petition for resolution of reimbursement dispute, pursuant to subsection 440.13(7), F.S.

96 – Paid: Payment made pursuant to a write-off by a health care provider self-insured employer.

       97 – Paid: no modification to the information provided on the medical bill; repackaged medication; reimbursed at repackaged methodology pursuant to paragraph 440.13(12)(c), F.S.

       98 - Paid: no modification to the information provided on the medical bill; dispensed medication; billed original manufacturer’s NDC number only; reimbursed pursuant to paragraph 440.13(12)(c), F.S.

(14) A claim administrator or any entity acting on behalf of the insurer to pay, adjust, disallow or deny a filed bill shall send to the health care provider an EOBR detailing the adjudication of the submitted bill by line item, utilizing only the EOBR codes and code descriptors per line item, as set forth in Rule 69L-7.740(13), F.A.C., and shall include the insurer name, Division issued insurer code number and corresponding insurer mailing address. However, an insurer may choose to append an internal reason code to the EOBR it submits to the health care provider, when utilizing an EOBR code set forth in Rule 69L-7.740(13), F.A.C., that includes a code descriptor requiring the insurer to provide additional specification. A claim administrator or any entity acting on behalf of the insurer shall notify the health care provider of notice of payment or notice of adjustment, 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 subsection 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 paragraph 440.13(7)(a), F.S. The requirements of this subpart do not apply to adjudication of a bill for pharmaceutical services provided by a pharmacist or pharmacy licensed under Chapter 465, F.S., and billed on a Form DFS-F5-DWC-10 or its electronic equivalent, where, prior to the services being rendered, a binding contract exists between the claim administrator or any entity acting on behalf of the insurer, and the pharmacist or pharmacy or its representative that governs and specifies the amount to be paid by or on behalf of the insurer for the services.

(15) Copies of hospital medical records shall be subject to charges allowed pursuant to Section 395.3025, F.S. and Section 440.13, F.S.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New _________. Editorial Note: Formerly 69L-7.602 and 69L-7.710, F.A.C.

 

69L-7.750 Insurer Electronic Medical Report Filing to the Division.

(1) Effective 3/16/05, all required medical reports shall be electronically filed with the Division by all insurers.

(2) Required data elements shall be submitted in compliance with the MEIG.

(3) The Division will notify the Sender on the “Medical Bill Acknowledgement” of the corrections necessary for rejected medical reports to be electronically re-filed with the Division. An insurer shall ensure all rejected medical reports are corrected and resubmitted successfully to meet the filing requirements of subsection 69L-7.750(5), F.A.C.

(4) Any Sender who experiences a catastrophic event resulting in the insurer’s failure to meet the reporting requirements in subsection 69L-7.740(5), F.A.C., shall submit a written or electronic request within 15 business days after the catastrophic event to the Division for approval to submit in an alternative reporting method and an alternative filing timeline. The request shall contain a detailed explanation of the nature of the event, date of occurrence, and measures being taken to resume electronic submission. The request shall also provide an estimated date by which electronic submission of affected electronic data interchange or EDI filings, as defined in the MEIG, will be resumed. Approval shall be obtained from the Division’s Bureau 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 by the Division if a catastrophic event prevents electronic transmission.

(5) When filing any medical report replacement that corrects or replaces a previously accepted medical report, the sender shall use the same control number as the original transaction using bill submission reason code “03”. The replacement report shall contain all information necessary to process the medical report including all services and charges from the medical bill as billed by the health care provider and all payments made by a claim administrator or entity acting on behalf of an insurer to the health care provider. Additionally, after being notified by the Division that data has been accepted with errors or that data previously accepted has been deemed inaccurate, a claim administrator or entity acting on behalf of an insurer shall correct or replace the inaccurate data, using the same control number as the original transaction and using bill submission reason code “03”. The insurer or the entity acting on behalf of the insurer shall respond to a written request from the Division to review, correct, and re-submit accurate data. Each Division written request shall have a specified timeline to which the insurer or entity acting on behalf of an insurer shall adhere.

(6) Each insurer shall be responsible for ensuring the accurate completion of the Medical EDI Bill Record Layouts Revision F for Records 09, 10, 11 and 90 as defined in and in accordance with the MEIG’s phase-in schedule, as denoted below.

(a) Senders with Sender FL ID  numbers 001 – 199, as defined in the MEIG, shall begin testing 150 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 195 days after the effective date of this rule.

(b) Senders with Sender FL ID numbers 200 – 899, as defined in the MEIG, shall begin testing 195 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 240 days after the effective date of this rule.

(c) Senders with Sender FL ID numbers 900 and above, as defined in the MEIG, shall begin testing 240 days after the effective date of this rule and shall complete the testing process with the new Revision “F” record layouts within 285 days after the effective date of this rule.

(d) The Division will, resources permitting, allow senders that volunteer to complete the test transmission processes earlier than the schedule denoted above. Each voluntary sender shall still have 45 days from the start date of testing to complete the test transmission to production transmission processes, for all Medical EDI Bill Records, that comply with requirements set forth and defined in the MEIG.

(7) Senders who do not accurately complete the testing requirements in accordance with the MEIG shall not submit Revision F medical Reports electronically until having been approved for reporting production data with the Division as necessary to meet the filing requirements of subsection 69L-7.750(5), F.A.C.

(8)(a) In the medical bill claims-handling process, the receipt of medical bills may be based upon receipt by the insurer or “entity” acting on behalf of an insurer. Likewise, the payment of medical bills may be based upon payment by the insurer or “entity” acting on behalf of an insurer. Therefore, to properly reflect “Date Insurer Received Bill” and “Date Insurer Paid Bill,” the insurer or entity acting on behalf of the insurer, shall be limited to the receipt and payment options of this subpart for the reporting of a medical bill:

1. Both receipt and payment of medical bills are handled by the insurer. This option may be utilized only when the “Date Insurer Received Bill” is the date the insurer gained possession of the health care provider’s medical bill, and the “Date Insurer Paid Bill” is the date the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. 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.

2. 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 Bill” 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 Bill” is the date an entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

3. 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 Bill” is the date the insurer gained possession of the health care provider’s medical bill, and the “Date Insurer Paid Bill” is the date an entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. 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.

4. 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 Bill” 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 Bill” is the date the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

(b) 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.

(c) The option in paragraph 69L-7.750(8)(a), F.A.C., selected by the insurer shall be identified on each medical report electronic submission to the Division and shall utilize the following coding methodology:

1. If the “Date Insurer Received Bill” is the date the insurer gains possession of the health care provider’s medical bill and the “Date Insurer Paid Bill” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 1, as defined in the MEIG, shall be transmitted on each individual electronic form equivalent transaction. (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG. When submitting Payment Code “x” 1 to the Division, the insurer is declaring that no “entity,” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling processes related to “Date Insurer Received Bill” or “Date Insurer Paid Bill”.

2. If the “Date Insurer Received Bill” 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 Bill” 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, as defined in the MEIG, shall be transmitted on each individual electronic form equivalent transaction. (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG. When submitting Payment Code “x” 2 to the Division, the insurer is declaring that the specified “entity” as defined in subsection 69L-7.710(1)(x), F.A.C., is acting on behalf of the insurer for purposes of the medical bill claims-handling processes related to “Date Insurer Received Bill” and “Date Insurer Paid Bill”.

3. If the “Date Insurer Received Bill” is the date the insurer gains possession of the health care provider’s medical bill and “Date Insurer Paid Bill” 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, as defined in the MEIG, shall be transmitted on each individual electronic form equivalent transaction. (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG. When submitting Payment Code “x” 3 to the Division, the insurer is declaring that no “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling process related to “Date Insurer Received Bill.”

4. If the “Date Insurer Received Bill” 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 Bill” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 4, as defined in the MEIG, shall be transmitted on each individual form electronic form equivalent transaction. (“x” shall equal ‘R’, ‘M’ or ‘C’ as denoted in the data dictionary of the MEIG. When submitting Payment Code “x” 4 to the Division, the insurer is declaring that no “entity” as defined in paragraph 69L-7.710(1)(x), F.A.C., is involved in the medical bill claims-handling processes related to “Date Insurer Paid Bill.”

(9) A Claim administrator or any entity acting on behalf of the insurer, when reporting paid medical claims data to the Division, shall report the dollar amount paid by the insurer or reimbursed to the employee, the employer or other insurer for healthcare service(s) or supply(ies). When reporting disallowed or denied charges, the dollar amount paid shall be reported as $0.00.

(10) A claim administrator or any entity acting on behalf of the insurer is not required to report electronically as medical payment data to the Division those payments made for federal facilities billing on their usual form, for duplicate medical bills, for medical bills outside the authority of Florida’s workers’ compensation system, or for health care providers in Rule 69L-7.730(2)(o), F.A.C., who bill on their invoice or letterhead.

(11) A claim administrator or any entity acting on behalf of the insurer, filing electronically, shall submit to the Division the EOBR code(s) relating to the adjudication of each line item billed and:

(a) Maintain the EOBR in a format that can be legibly reproduced, and

(b) When reporting production data in accordance with the MEIG as required in subsection 69L-7.750(6), F.A.C., the insurer shall comply with the EOBR instructions contained in subsection 69L-7.740(13), F.A.C.

(12) A claim administrator, sender or any entity acting on behalf of the insurer shall make available to the Division, upon request and without charge, a legibly reproduced copy of the electronic form equivalents of 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 the insurer written documentation required in subsection 69L-7.740(10), F.A.C.

(13) When a claim administrator or any entity acting on behalf of the insurer renders reimbursement following receipt of a determination or final order in response to a petition to resolve a reimbursement dispute filed pursuant to subsection 440.13(7), F.S., the insurer shall:

(a) Submit the required data elements to the Division within 45 days of rendering reimbursement; and

(b) Submit the data as a replacement submission pursuant to the MEIG; and

(c) Submit the cumulative, not the supplemental, payment information at the line-item level utilizing EOBR code 95 for each line-item reflecting a payment amount differing from the payment amount reported on the original submission; and

(d) Report the “Date Insurer Received Bill” as 22 days after the date the determination was received by certified mail, in instances where the insurer has waived its rights under Chapter 120, F.S., or report the “Date Insurer Received Bill” as the date the insurer received the final order by certified mail, in instances where the insurer has invoked its rights pursuant to Chapter 120, F.S., whichever occurs first.

(14) When a claim administrator or any entity acting on behalf of the insurer has reported medical claims data to the Division which were not required, the claim administrator or any entity acting on behalf of the insurer shall withdraw the previously reported data, as described in the MEIG.

(15) When an insurer, claim administrator, or any entity acting on behalf of the insurer renders reimbursement for multiple bills received from a health care provider, the insurer shall report required data elements to the Division for each individual bill, including “Date Insurer Received Bill” and “Date Insurer Paid Bill”, submitted by the health care provider and shall not combine multiple bills received from a health care provider into a single medical bill transaction.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New ______, Editorial Note: Formerly 69L-7.602 and 69L-7.710, F.A.C.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Pamela Macon, Chief, 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: May 6, 2015

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: June 3, 2014