The proposed rule amendment reduces regulatory burdens placed on insurers under existing provisions of the rule. In the case of medical bills for pharmaceuticals or pharmaceutical services provided by a pharmacy or pharmacist under Chapter 465, F.S.,...

 

DEPARTMENT OF FINANCIAL SERVICES

Division of Worker's Compensation

RULE NO.:RULE TITLE:

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

PURPOSE AND EFFECT: The proposed rule amendment reduces regulatory burdens placed on insurers under existing provisions of the rule. In the case of medical bills for pharmaceuticals or pharmaceutical services provided by a pharmacy or pharmacist under Chapter 465, F.S., the insurer, service company/TPA or any entity acting on behalf of the insurer, would be relieved of the obligation of issuing an Explanation of Bill Review (“EOBR”) to that pharmacy or pharmacist if there is a preexisting contract between the two that governs and specifies the amount of reimbursement due on the medical bill.

SUMMARY: The rule is amended to provide that insurers, or other entities acting on behalf of an insurer, are not required to issue an Explanation of Bill Review to pharmacists for pharmaceutical services in cases where a preexisting contract between the parties specifies the terms of reimbursement for the services provided.

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 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 agency has determined that the proposed amendments to the rule chapter are not expected to require legislative ratification based on the information expressly relied upon and described herein: 1) no requirement for a SERC was triggered under subsection 120.54(1) and paragraph 120.54(3)(b), F.S.; and 2) there are no adverse impacts or regulatory costs associated with the proposed rules that will exceed any of the criteria established in paragraph 120.541(2)(a), F.S.

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), 440.185(5), (9), 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: Thursday, September 12, 2013 @ 10:00 a.m.

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

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Eric Lloyd @ [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: Eric Lloyd, Program Administrator, Office of Medical Services, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4232, [phone] or [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

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

(1) through (4) No change.

(5) Insurer Responsibilities.

(a) through (p) No change.

(q) An insurer, service company/TPA or any entity acting on behalf of the insurer to pay, adjust, disallow or deny a filed bill shall submit to the health care provider an Explanation of Bill Review 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 paragraph (o) of this section, and shall include the insurer name, Division issued insurer 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 paragraph (o) that includes a code descriptor requiring the insurer to provide additional specification. An insurer, service company/TPA or any entity acting on behalf of the insurer shall notify the health care provider of notice of payment or notice of adjustment, disallowance or denial only through an EOBR. An EOBR shall specifically state that the EOBR constitutes notice of disallowance or adjustment of payment within the meaning of Section 440.13(7), F.S. An EOBR shall specifically identify the name and mailing address of the entity the carrier designates to receive service on behalf of the “carrier and all affected parties” for the purpose of receiving the petitioner’s service of a copy of a petition for reimbursement dispute resolution by certified mail, pursuant to Section 440.13(7)(a), F.S. The requirements of this paragraph 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 insurer, service company/TPA 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.

(r) through (v) No change.

(6) No change.

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), (f), 440.185(5), 440.20.(6)(b), 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), (f), (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,_________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Eric Lloyd, Program Administrator, Office of Medical Services, Division of Workers’ Compensation, Department of Financial Services

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Jeff Atwater, Chief of Financial Officer, Department of Financial Services

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: August 1, 2013

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 22, 2013