Petition Form, Carrier Response Form, Petition Requirements, Service of Petition on Carrier and Affected Parties, Computation of Time, Carrier Response Requirements, Reimbursement Disputes Involving a Contract or Workers' Compensation Managed Care ...
DEPARTMENT OF FINANCIAL SERVICES
Division of Worker’s Compensation
RULE NOS.:RULE TITLES:
69L-31.003Petition Form
69L-31.004Carrier Response Form
69L-31.005Petition Requirements
69L-31.007Service of Petition on Carrier and Affected Parties
69L-31.008Computation of Time
69L-31.009Carrier Response Requirements
69L-31.016Reimbursement Disputes Involving a Contract or Workers' Compensation Managed Care Arrangement
69L-31.017Carrier and Health Care Provider Non-compliance
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. 42 No. 236, December 7, 2016 issue of the Florida Administrative Register.
The changes to the proposed rules are in response to oral testimony and written comments submitted to the Department by interested parties and to written comments submitted to the Department by the staff of the Joint Administrative Procedures Committee. Changes are also made to incorporated Forms DFS-F6-DWC-3160-0023 (Petition for Resolution of Reimbursement Dispute) and DFS-F6-DWC-3160-0024 (Carrier Response to Petition for Resolution of Reimbursement Dispute) to provide additional clarification concerning required documentation and to harmonize the forms with rule and statute.
69L-31.003 Petition for Resolution of Reimbursement Dispute Form.
(1) The Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0023, Revised 03/2017 (“Petition Form”), is hereby incorporated by reference herein and adopted for use in rules listed under Rule Chapter 69L-31, F.A.C. in this rule chapter. This form may be obtained on the Department’s website at http://www.myfloridacfo.com/Division/WC/pdf/DFS-3160-0023(rev2017).pdf or by contacting the Department at (850)413-1613.
(2) All references to a “petitioner” in this rule and as used throughout rules listed under Rule Chapter 69L-31, F.A.C., chapter are to the health care provider or entity acting on behalf of the health care provider submitting a Petition Form to contest carrier disallowance or adjustment of payment.
(3) No change.
69L-31.004 Carrier Response to Petition for Resolution of Reimbursement Dispute Form.
(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute Form, DFS-F6-DWC-3160-0024, Revised 03/2017 (“Response Form”), is hereby incorporated by reference herein, and adopted for use throughout rules listed under Rule Chapter 69L-31, F.A.C in this rule chapter. This form may be obtained on the Department’s website at http://www.myfloridacfo.com/Division/WC/pdf/DFS-3160-0024(rev2017).pdf or by contacting the Department at (850)413-1613.
(2) All references to a “carrier” in this rule and throughout rules listed under Rule Chapter 69L-31, F.A.C., chapter include the carrier or any entity acting on the carrier’s behalf in administering the carrier’s workers’ compensation medical claims.
(3) The Response Form will be the only form accepted by the Department upon which a carrier may submit its response to a Petition Form to contest carrier disallowance or adjustment of payment pursuant to paragraph 440.13(7)(b), F.S., and must be submitted in hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/. Information contained in the Explanation of Bill Review (EOBR) or notice of disallowance or adjustment of payment will control for purposes of establishing the carrier’s basis for disallowance or adjustment of payment.
69L-31.005 Petition Form Requirements and Reasons for Dismissal.
(1) No change.
(2) The petitioner must submit the Petition Form and all documentation supporting the allegations contained in the Petition Form. The supporting documentation of the items listed below must be submitted by hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/:
(a) through (e) No change.
(f) If the reimbursement dispute involves repackaged medication, a copy of the Prescription (Legend) Drug Pedigree documenting the ownership and distribution history of that medication.
(f)(g) If the reimbursement dispute involves services provided by a hospital, an itemized statement with charges based on the facilities charge master applicable to the date(s) of service must be submitted documentation of the portions of the hospital’s charge master pertinent to the billed services as of the date of service.
(g)(h) No change.
(3) through (4) No change.
69L-31.007 Service of Petition on Carrier and Affected Parties.
(1) The petitioner must effectuate service on the carrier and on all affected parties by serving a copy of the Petition Form and all supporting documentation submitted to the Department, by United States Postal Service (henceforth referred to as “USPS” throughout rules listed under Rule Chapter 69L-31, F.A.C. this rule chapter) certified mail on the specific entity identified on the Explanation of Bill Review (“EOBR”) or notice of disallowance or adjustment of payment as the entity the carrier designates to receive service of the Petition Form and copies of all supporting documentation on behalf of the carrier and all affected parties. If the EOBR or notice of disallowance or adjustment of payment does not specify a name and mailing address for the entity the carrier designates to receive service on behalf of the carrier and all affected parties, as required by subsection 69L-7.740(14), F.A.C., the petitioner may effectuate service of the Petition Form on the carrier and all affected parties by serving a copy of the Petition Form and copies of all supporting documentation in support of the Petition Form by USPS certified mail on the entity that issued the EOBR or notice of disallowance or adjustment of payment at the address from which the EOBR or notice of disallowance or adjustment of payment was issued.
(2) The Petition Form must be served on the carrier and all affected parties by USPS certified mail. Service on the carrier must include one copy of all documentation submitted to the Department in support of the Petition Form.
(3) through (4) No change.
(5) References to “all affected parties,” as used herein and throughout rules listed under Rule Chapter 69L-31, F.A.C., refers to the entity acting on the carrier’s behalf or the entity the carrier designates to receive service.
69L-31.008 Computation of Time.
(1)(a) through (d) No change.
(e) If receipt cannot be established through a date stamp or verifiable login process, the health care provider may provide with the petition a copy of the envelope in which the Explanation of Bill Review or notice of disallowance or adjustment of payment was sent which clearly and legibly shows the postmark date, in which case receipt will be deemed to be five (5) calendar days from the postmark date on the envelope in which the Explanation of Bill Review or notice of disallowance or adjustment of payment was sent. If the health care provider does not establish the date of its receipt of the Explanation of Bill Review or notice of disallowance or adjustment of payment by any of the methods set forth in this subsection through documentation accompanying the Petition, the health care provider receipt of the Explanation of Bill Review or adjustment of payment or notice of disallowance will be deemed to be five (5) calendar days from the issue date on the Explanation of Bill Review or notice of disallowance or adjustment of payment. An affidavit attesting to date of receipt will not be accepted as proof of date of receipt.
(2) through (5) No change.
69L-31.009 Carrier Response Requirements.
(1) The Response Form, accompanied by all supporting documentation in hard copy or by electronic submission via the Division of Workers Compensation Web Portal at https://msuwebportal.fldfs.com/, must be served on the Department no later than thirty (30) calendar days after the carrier’s receipt of a copy of the Petition Form by USPS certified mail. The carrier’s response to the Petition Form must include a completed Response Form.
(2) through (3) No change.
69L-31.016 Reimbursement Disputes Involving a Contract or Workers’ Compensation Managed Care Arrangement or Involving Compensability or Medical Necessity.
(1) No change.
(2) When the carrier asserts the treatment is not compensable or medically necessary and as a result does not reimburse, the Department will not issue a finding that there has been any improper disallowance or adjustment. Instead, the determination will only address line items not related to indicate the reimbursement amount for the treatment established by the appropriate reimbursement schedules, practice parameters, and protocols of treatment under Chapter 440, F.S., should compensability or medical necessity be later established. If the petitioner has submitted documentation demonstrating the carrier authorized the treatment, the Department will issue a finding of improper disallowance or adjustment.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (12)(a), 440.134(15) FS. History–New__________.
69L-31.017 Carrier and Health Care Provider Non-compliance
(1) The Department may issue an order compelling the carrier to correct its reimbursement practices. Failure by the carrier to correct such practices will result in the issuance of a willful violation pursuant to Rule 69L-24.007, F.A.C., in addition to any fines issued pursuant to paragraph 440.13(7)(f), F.S. Improper carrier reimbursement practices include by the carrier’s failure to comply with the provisions of subsection 440.13(7), F.S., and guidelines established under Rule 69L-7.740, F.A.C., and include, but are not limited to, the following:
(a) through (e) No change.
(2) No change.
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (8)(b), (11)(a), (12), 440.525 FS. History–New__________.
The remainder of the proposed rule notice reads as previously published.
