Notice of Change/Withdrawal
DEPARTMENT OF FINANCIAL SERVICES
Division of Workers’ Compensation
RULE NO.:RULE TITLE:
69L-7.020Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
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. 47, No. 24, February 5, 2021, issue of the Florida Administrative Register.
The proposed rule was previously amended through Notices of Change in the Vol. 47/82, April 28, 2021, and Vol. 47/118, June 18, 2021, issues of the Florida Administrative Register.
69L-7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.
(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual (HCP RM), 2020 Edition, effective July 1, 2022 2021, is incorporated by reference as part of this rule. The HCP RM contains the Maximum Reimbursement Allowances (MRAs) determined by the Three-Member Panel, pursuant to section 440.13(12), F.S., and establishes reimbursement policies, guidelines, codes, and MRAs for services provided by health care providers. Also, the HCP RM includes reimbursement policies and payment methodologies for pharmacists and medical suppliers. The policies and procedures in the HCP RM are in addition to the requirements and responsibilities established throughout Rule Chapter 69L-7, F.A.C., Workers’ Compensation Medical Reimbursement and Utilization Review.
(2) through (3) No change.
The Florida Workers’ Compensation Health Care Provider Reimbursement Manual (HCP RM), incorporated by reference in subsection 69L-7.020(1), is modified as follows:
Page 1 and footers of pages 2-377: The effective date is changed from July 1, 2021 to July 1, 2022.
Page 6:
The following paragraph in the “Health Care Provider Responsibilities” section is deleted in its entirety:
Reimbursement for services or procedures not listed in the Fee Schedule must be made according to an agreed upon contract price. Therefore, at the time of request for authorization, a health care provider should inform the carrier of any services or procedures that are not listed in the Fee Schedule.
The following paragraph is added below the current text in the “Prior Authorization of Services” section:
Medical authorization is an integral component of an efficient and self-executing workers’ compensation system. The request for authorization and the timely decision to authorize or not authorize has a direct impact on the injured worker’s medical care and treatment, the length of time the injured worker is out of work, whether the injured worker hires an attorney, health care provider participation in the workers’ compensation system, the cost of the claim, and the number of medical reimbursement disputes. Therefore, it is imperative the health care provider clearly and comprehensively communicates the requested treatment to the carrier and for the insurance carrier to ask clarifying questions or request additional documentation to facilitate authorization.
Page 7:
The following changes are made to the “Billing New Procedure Codes Not Listed in the Fee Schedule” section:
- The following sentence is deleted form the section: “Reimbursement for services or procedures not listed in the fee schedule must be made according to an agreed upon contract price.”
- The sentence “Note: See Codes with No MRAs in this Manual.” is changed to “Note: For reimbursement see Codes with No MRAs in this Manual.”
Page 12:
The text within the “Codes with No MRAs” section is deleted in its entirety and replaced with the following text:
When the health care provider bills a valid procedure code found in the CPT® or the HCPCS Level II® manual that corresponds to the date of service, and the procedure code is not listed in the fee schedule in this Manual, reimbursement is determined by:
• Comparing the billed procedure code with a clinically similar procedure code found in this Manual;
• The health care provider’s documentation and medical bills; or
• The National Physician Fee Schedule Relative Value File copyrighted by the American Medical Association.
At a minimum, reimbursement must be the Florida Workers’ Compensation MRA for a clinically similar procedure code that is listed in this Manual or an agreed upon contract price.
Carriers must have an established methodology for determining reimbursement for procedure codes that are not listed in this Manual and the methodology must be available upon request by the Division.
Page 370:
The following text in the “Heath Care Providers Who Bill on the DWC-9” section is deleted in its entirety:
Reimbursement for services or procedures not listed in the fee schedule must be made according to an agreed upon contract price.
Examples include:
• Services or procedures not described in the incorporated CPT® manual requiring the use of an unlisted procedure code for billing; and
• CPT® codes with a substantial description change or newly adopted codes in the CPT® manual published subsequent to this Manual.
