Petition Form, Petition Requirements

DEPARTMENT OF FINANCIAL SERVICES

Division of Workers’ Compensation

RULE NOS.:RULE TITLES:

69L-31.003Petition Form

69L-31.005Petition Requirements

 

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with Section 120.54(3)(d)1., F.S., published in Vol. 45, No. 228, November 22, 2019, issue of the Florida Administrative Register, as amended in the Notices of Change published in Vol. 46, No. 246, December 21, 2020, issue of the Florida Administrative Register and in Vol. 47, No. 36, February 23, 2021 issue of the Florida Administrative Register.

 

69L-31.003 Petition for Resolution of Reimbursement Dispute Form and Requirements.

(1) through (2) No change.

(3) The Petitioner must submit the Petition Form to the Department within the timeframe set forth in section 440.13(7)(a), F.S., and must include with the Petition Form the documents listed below that support the allegations contained in the Petition Form:

(a) through (d) No change.

(e) If the Medical Necessity of the services in the Notice of Disallowance or Adjustment are being disputed, either a Letter of Medical Necessity signed by the Health Care Provider who provided the services in the contested line item(s) in the Notice of Disallowance or Adjustment describing the Medical Necessity of the services, or supporting medical notes and records for the line item(s) in dispute must be provided; a Letter of Medical Necessity signed by the Health Care Provider who provided the services in the contested line item(s) in the Notice of Disallowance or Adjustment describing the Medical Necessity of the services may be provided in addition to the supporting medical notes and records;

(f) through (g) No change.

(4) No change.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.003, Amended ___.

 

69L-31.005 Written Determinations.

(1) through (2) No change.

(3) Failure by the Carrier to issue an Explanation of Bill Review (EOBR) that meets the requirements of subsection 69L-7.740(14), F.A.C., may result in a determination in favor of the Petitioner, along with one or more of the following penalties in sections 440.13(7)(f) and 440.525, F.S., and Rule 69L-24.007, F.A.C.

Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), 440.13(9), 440.13(11) FS. History–New 11-28-06, Formerly 59A-31.005, Amended ___.