The purpose of the proposed rules is to substantially reword the existing rule to establish uniform procedures and form filing requirements for health care providers and employer/carriers regarding AHCA resolution of workers’ compensation ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION
Health Facility and Agency Licensing

RULE NO: RULE TITLE
59A-31.002: Disputed Reimbursement Resolution
59A-31.003: Petition Form
59A-31.004: Carrier Response Form
59A-31.005: Petition Requirements
59A-31.006: Consolidation of Petitions
59A-31.007: Service of Petition on Carrier and Affected Parties
59A-31.008: Computation of Time
59A-31.009: Carrier Response Requirements
59A-31.010: Effect of Non-Response by Carrier
59A-31.011: Complete Record
59A-31.012: Petition Withdrawal
59A-31.013: Overutilization Issues Raised in Reimbursement Dispute Resolution
59A-31.014: Managed Care Arrangements
59A-31.015: Managed Care Arrangements
PURPOSE AND EFFECT: The purpose of the proposed rules is to substantially reword the existing rule to establish uniform procedures and form filing requirements for health care providers and employer/carriers regarding AHCA resolution of workers’ compensation reimbursement disputes.
SUMMARY: The proposed rule enumerates the procedural requirements of the Agency’s Reimbursement Dispute process.
SUMMARY OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
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.
SPECIFIC AUTHORITY: 440.13(7), 440.134(25)(e), 440.591 FS.
LAW IMPLEMENTED: 440.13(7) FS.
A HEARING WILL BE HELD AT THE TIME, DATE AND PLACE SHOWN BELOW:
TIME AND DATE: August 11, 2006, 10:00 a.m. – 12:00 Noon
PLACE: Room 104-J, Hartman Bldg., 2012 Capital Circle, S.E., Tallahassee, Florida
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Beverly J. Williams, Medical Health Care Program Analyst, AHCA, Workers’ Compensation Unit, 2012 Capital Circle, Southeast, Tallahassee, Florida 32399-4232

THE FULL TEXT OF THE PROPOSED RULE IS:

59A-31.002 Disputed Reimbursement.

Specific Authority 440.13(7) FS. Law Implemented 440.13(2)(a)(i) FS. History–New 5-15-1991, Formerly 38F-7.517, 4L-7.517, F.A.C. Amended 4-2-06, Repealed________.

 

59A-31.003 Petition Form.

(1) The Petition for Resolution of Reimbursement Dispute Form (AHCA Form 3160-0023) is hereby incorporated by reference. This form may be obtained on the Internet at http://www.fldfs.com/wc/forms.html or by contacting the Agency at [phone].

(2) A petition to contest carrier disallowance or adjustment of payment pursuant to Section 440.13(7)(a), F.S., must be on the Petition for Resolution of Reimbursement Dispute form. Any submission seeking to contest the disallowance or adjustment of payment by a carrier pursuant to Section 440.13(7)(a), F.S., must include a completed Petition for Resolution of Reimbursement Dispute form.

Specific Authority 440.13(7)(e) FS. Law Implemented 440.13(7)(a) FS. History–New _________

 

59A-31.004 Carrier Response Form.

(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA Form 3160-0024) is hereby incorporated by reference. This form may be obtained on the Internet at http://www.fldfs.com/wc/forms.html or by contacting the Agency at [phone].

(2) The Carrier Response to Petition for Resolution of Reimbursement Dispute form shall be considered a required element of the requested documentation to the Agency under Section 440.13(7)(b), F.S. The Carrier Response to Petition for Resolution of Reimbursement Dispute form shall be the only form accepted by the Agency upon which a carrier may submit to the Agency its response to a Petition for Resolution of Reimbursement Dispute. Any submission by a carrier pursuant to Section 440.13(7)(b), F.S., that does not include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute form shall result in a notice of deficiency by the Agency. A carrier shall have 10 calendar days from receipt of the notice of deficiency to cure the deficiency identified in the Agency notice of deficiency. Failure to timely cure the deficiency shall constitute failure to submit requested documentation to the Agency.

Specific Authority 440.13(7)(e) FS. Law Implemented 440.13(7)(b) FS. History–New________.

 

59A-31.005 Petition Requirements.

(1) All documents and records that support the allegation contained in the petition must accompany the petition. A petition that is accompanied by all items specified below will not be dismissed for failure to submit supporting documents and records:

(a) A copy of each Explanation of Bill Review received from the carrier providing notice of disallowance or adjustment of payment in this dispute.

(b) A copy of the medical bill or medical bills or request for reimbursement for which payment was disallowed or adjusted by the carrier on the contested Explanation of Bill Review(s).

(c) All medical documentation and records submitted to the carrier in support of the medical bill(s) or request(s) for reimbursement, which are the subject of this dispute.

(d) If the answer to question 5 on the Petition for Resolution of Reimbursement Dispute form is yes, a copy of all applicable provision(s) of the reimbursement contract.

(e) Provider’s documentation of authorization by carrier for non-emergency treatment for the date(s) of service covered by the petition.

(f) Documentation of health care provider notification to the carrier, pursuant to Section 440.13(3)(b), F.S., for emergency treatment for the date(s) of service included in the petition.

(2) If the petitioner does not submit a completed Petition for Resolution of Reimbursement Dispute form, accompanied by all of the items specified in 59A-31.005(1), F.A.C., the petitioner will be notified by the Agency of the deficiency in submission. The petitioner shall have 10 calendar days from receipt of the notice of deficiency to care the deficiency by providing to the Agency the items specified in the Agency notice along with proof of proper service of the curative documentation on the carrier. If the Agency does not receive the curative documentation and proof of service of the curative documentation on the carrier within 10 days after petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice.

(3) Documents and records accompanying the petition must be submitted in hard copy.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New________.

 

59A-31.006 Consolidation of Petitions.

(1) If multiple petitions addressing the same substantive issue(s) have been filed by petitioner contesting disallowance or adjustment of payment by the same carrier, the Agency may, in its discretion, consolidate the petitions into a single determination.

(2) If the Agency consolidates multiple petitions into a single determination, the timetable for rendering a determination upon a consolidated petition shall be expanded to 120 days after Agency receipt of all documentation.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(e) FS. History–New_________.

 

59A-31.007 Service of Petition on Carrier and Affected Parties.

(1) The petitioner shall effectuate service on the carrier and on all affected parties by serving a copy of the petition and all documents and records in support of the petition, by United States Postal Service (USPS) certified mail on the entity identified on the Explanation of Bill Review as the entity the carrier designates to receive service on behalf of the carrier and all affected parties. If the Explanation of Bill Review does not 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, as required by paragraph  69L-7.602(5)(q), F.A.C., the petitioner may effectuate service of the petition on the carrier and all affected parties by serving a copy of the petition and all documents and records in support of the petition by United States Postal Service (USPS) certified mail, on the entity who issued the Explanation of Bill Review at the address from which the Explanation of Bill Review was issued.

(2) A Petition for Resolution of Reimbursement Dispute must be served on the carrier and all affected parties by United States Postal Service (USPS) certified mail. Service on the carrier shall include all documents and records submitted to the Agency in support of the petition.

(3) Service by certified mail means service by United States Postal Service (USPS) certified mail. Service by United States Postal Service (USPS) delivery other than certified mail or service by common carrier does not constitute service by certified mail, as required by statute, even if carrier delivery and receipt of the petition are confirmed.

(4) If a carrier has not been properly served in accordance with this subsection, the petitioner will be notified by the Agency of the deficiency in service. The petitioner shall have 10 calendar days from receipt of the notice of deficiency in service to provide the Agency with proof the deficiency in service identified in the notice of deficiency has been cured by proper service. If the Agency does not receive proof of proper service within 10 days after petitioner’s receipt of the notice of deficiency, the petition will be dismissed with prejudice. For purposes of this rule, “proof of proper service” means that a copy of the petition and all documents and records in support of the petition have been sent by United States Postal Service (USPS) certified mail to the proper entity at the proper address as set forth in this rule, and a certified mail receipt number is provided to the Agency to confirm mailing.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a) FS. History–New________.

 

59A-31.008 Computation of Time.

(1) Pursuant to paragraph 69L-7.602(5)(q), F.A.C., notice of disallowance or adjustment of payment, which begins the 30 day time period in Section 440.13(7), F.S., shall only be through receipt of an Explanation of Bill Review issued by or on behalf of a carrier. Therefore, the 30 day time period within a petition must be served upon the Agency begins upon receipt of the Explanation of Bill Review by the health care provider or by an entity designated by the provider to receive such notice on behalf of the health care provider. The health care provider shall document receipt of the Explanation of Bill Review using a date stamp, which clearly reflects date of receipt, or by using a verifiable login process. Documentation of receipt through a date stamp or verifiable login process shall accompany the petition. A date stamped Explanation of Bill Review will be accepted as proof of date of receipt by date stamp. A copy of the applicable portion of the login roster showing the date of login of the Explanation of Bill Review will be accepted as proof of receipt through a verifiable login process. 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 was sent which clearly and legibly shows the postmark date, in which case receipt will be deemed to be 5 calendar days from the postmark date on the envelope in which the Explanation of Bill Review was sent. If the health care provider does not establish the date of its receipt of the Explanation of Bill Review by any of the methods set forth in this paragraph through documentation accompanying the Petition, the health care provider receipt of the Explanation of Bill Review will be deemed to be 5 calendar days from the issue date on the Explanation of Bill Review. An affidavit attesting to date of receipt will not be accepted as proof of date of receipt.

(2) Petitioning the Agency shall be effectuated upon service of the petition upon the Agency. The timeliness of a Petition for Resolution of Reimbursement Dispute shall be calculated based upon service of the petition upon the Agency. Service upon the Agency shall be by United States Postal Service (USPS) mail, by common carrier, or by hand delivery. If service is by United States Postal Service mail, the date of service shall be postmark date. If service is by common carrier, the date of service shall be the common carrier pick-up date. If service is by hand delivery, the date of service is the date the petition is hand delivered to: Receptionist, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida. Service by hand delivery is available Monday through Friday between 8:00 a.m. and 5:00 p.m., Eastern Time, excluding state holidays.

(3) Carrier date of receipt of the petition by certified mail will be established by reference to the United States Postal Service (USPS) certified mail receipt date. Timely submission by the carrier of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and accompanying documentation to the Agency shall be determined based upon the date of service of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and accompanying documentation to the Agency. If service is by United States Postal Service mail, the date of service shall be the postmark date. If service is by common carrier, the date of service shall be the common carrier pick-up date. If service is by hand delivery, the date of service is the date the petition is hand delivered to: Receptionist, Hartman Building, 2012 Capital Circle Southeast, Tallahassee, Florida. Service by hand delivery is available Monday through Friday between 8:00 a.m. and 5:00 p.m., Eastern Time, excluding state holidays.

(4) Neither the request for, nor the conducting of, an on-site audit or referral of the health care provider for peer review consultation or independent medical examination shall toll the timeframe for petitioning the Agency for the resolution of a reimbursement dispute as set forth in Section 440.13(7)(a), F.S., or for the carrier to submit requested documentation under Section 440.13(7)(b), F.S.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(a), (b) FS. History–New________.

 

59A-31.009 Carrier Response Requirements.

(1) The Carrier Response to Petition for Resolution of Reimbursement Dispute form, accompanied by all requested information, must be served on the Agency within 10 days after receipt of a copy of the petition by certified mail. The carrier’s response to the petition must include a completed Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA form 3160-0024). Failure of the carrier to meet these requirements constitutes waiver of all objection to the petition.

(2) The carrier shall provide the petitioner, using a delivery method which provides confirmation of date of delivery, at the petitioner’s mailing address on the Petition for Resolution of Reimbursement Dispute form, copies of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and all accompanying information served on the Agency in response to the petition.

(3) Documents and records accompanying the carrier’s Response to Petition for Resolution of Reimbursement Dispute form must be in hard copy.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New________.

 

59A-31.010 Effect of Non-Response by Carrier.

(1) Failure of the carrier to timely submit a Carrier Response to Petition for Resolution of Reimbursement Dispute form (AHCA form 3160-0024) and accompanying documentation substantiating its disallowance or adjustment of payment constitutes a waiver of all objections to the petition. Waiver of all objections to the petition shall result in the Agency determination and final order being based solely upon the allegations and supporting documentation submitted by the petitioner.

(2) If a carrier has waived all objections to the petition under Section 440.13(7), F.S., with regard to a particular disallowance, adjustment or denial of payment, the carrier has also waived relief under Section 440.13(8) or 440.13(11), F.S., with regard to the payment(s) that was in dispute in the petition under Section 440.13(7), F.S.

Specific Authority 440.13(7). 440.591 FS. Law Implemented 440.13(7)(b) FS. History–New________.

 

59A-31.011 Complete Record.

The evidentiary record upon which the Agency determination will be made shall be the Petition for Resolution of Reimbursement Dispute and all supporting documents and records accompanying the petition and the Carrier’s Response to Petition for Resolution of Reimbursement Dispute and all accompanying documents. However, if the petitioner and carrier enter into a joint stipulation of the parties pursuant to Rule 59A-31.012, F.A.C., the evidentiary record upon which the Agency determination will be made shall also include all additional supporting documentation submitted to the Agency by the parties within the 10 calendar day period provided for in Rule 59A-31.012, F.A.C.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(c) FS. History–New__________.

 

59A-31.012 Joint Stipulation of the Parties.

Within 14 calendar days subsequent to service on the Agency of the carrier response, the petitioner and carrier may serve on the Agency a joint stipulation of the parties, mutually stipulate in writing that the reimbursement dispute be held in abeyance for a specified time period, not to exceed 60 calendar days, for the parties to seek a resolution of the reimbursement dispute without the need for a determination by the Agency. Service of a joint stipulation of the parties on the Agency shall be by one of the methods by which a petition is served on the Agency in subsection 59A-31.008(2), F.A.C. At the conclusion of the specified time period in the joint stipulation of the parties, or upon earlier notice in writing served upon the Agency and the other party(ies) to the joint stipulation by any party to the joint stipulation of the parties that the negotiations to resolve the reimbursement dispute are at an impasse, the Agency will proceed to make a determination on the reimbursement dispute. At the time the abeyance of the dispute is concluded, the Agency will allow both parties 10 calendar days to serve any additional supporting documentation a party wishes to be considered in making a determination on the dispute. If a reimbursement dispute is held in abeyance pursuant to a joint stipulation of the parties, the 60-day time period for the Agency to issue a determination shall commence when the 10-day period for serving additional documentation ends.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New________.

 

59A-31.013 Petition Withdrawal.

(1) Prior to the issuance of a determination the petitioner may voluntarily withdraw its Petition for Resolution of Reimbursement Dispute.

(2) Withdrawal of a petition shall be in writing and must clearly indicate:

(a) The name of the health care provider or facility requesting withdrawal;

(b) The name of the carrier against whom the petition has been initiated;

(c) The date(s) of service covered by the petition; and,

(d) The identity of the injured employee to whom medical services were delivered.

(3) The result of receipt by the Agency of a request for withdrawal of a petition shall be dismissed of the determination case by the Agency.

Specific Authority 440.13(7)(e). 440.591 FS. Law Implemented 440.13(7)(a)(c) FS. History–New________.

 

59A-31.014 Overutilization Issues Raised in Reimbursement Dispute Resolution.

If the carrier, in its response to the petition for Resolution of Reimbursement Dispute, asserts and submits documentation substantiating that a basis for disallowing petitioner’s claim for payment is overutilization and the Agency, in its discretion, determines that the reimbursement dispute cannot be resolved without addressing issue, the Agency will issue a determination pursuant to Section 440.13(7), F.S., that the reimbursement dispute cannot be resolved under Section 440.13(7), F.S., and is being converted to a proceeding under Section 440.13(8) and/or 440.13(11), F.S.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7)(b)(c) FS. History–New________.

 

59A-31.015 Managed Care Arrangements.

A health care provider may not elect to contest under Section 440.13(7), F.S., disallowance or adjustment of payment by a carrier for services rendered pursuant to a managed care arrangement.

Specific Authority 440.13(7)(e). 440.134(25)(e), 440.591 FS. Law Implemented 440.13(7) FS. History–New_________.

NAME OF PERSON ORIGINATING PROPOSED RULE: Beverly J. Williams, Medical Health Care Program Analyst
NAME OF SUPERVISOR OR PERSON WHO APPROVED THE PROPOSED RULE: Tom Warring, Chief, Bureau of Managed Health Care, Division of Health Quality Assurance
DATE PROPOSED RULE APPROVED BY AGENCY HEAD: 6/28/2006
DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: March 17, 2006