69L-7.720. Forms Incorporated by Reference for Medical Billing, Filing and Reporting

(1) The following forms, including form completion instructions, are incorporated for use with rules adopted under this rule chapter.

(a) Form DFS-F5-DWC-9/CMS-1500 Health Insurance Claim Form, Rev. 02/12; Completion Instructions for Form DFS-F5-DWC-9 are comprised of three sets.

1. Form DFS-F5-DWC-9-A, http://www.flrules.org/Gateway/reference.asp?No=Ref-06186, Completion Instructions for Physicians and Recognized Practitioners, Rev. 01/01/2015;

2. Form DFS-F5-DWC-9-B, http://www.flrules.org/Gateway/reference.asp?No=Ref-06187, Completion Instructions for Work Hardening and Pain Management Programs, Rev. 01/01/2015;

3. Form DFS-F5-DWC-9-C, http://www.flrules.org/Gateway/reference.asp?No=Ref-06188, Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (only for dates of services prior to July 8, 2010);

(b) Form DFS-F5-DWC-10, http://www.flrules.org/Gateway/reference.asp?No=Ref-06189, Statement of Charges for Drugs and Medical Equipment & Supplies Form, Rev. 01/01/2015; Form DFS-F5-DWC-10-A, http://www.flrules.org/Gateway/reference.asp?No=Ref-06190, Completion Instructions for Pharmacies and Home Medical Equipment Providers/Suppliers, Rev. 12/08/2015;

(c) Form DFS-F5-DWC-11, American Dental Association Dental Claim Form, Rev. 2012; Form DFS-F5-DWC-11-A, http://www.flrules.org/Gateway/reference.asp?No=Ref-06191, Completion Instructions for Dentists, Rev. 01/01/2015;

(d) Form DFS-F5-DWC-25, http://www.flrules.org/Gateway/reference.asp?No=Ref-06192, Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form, Rev. 1/31/2008; Form DFS-F5-DWC-25-A, http://www.flrules.org/Gateway/reference.asp?No=Ref-06193, Completion Instructions for Physicians and Recognized Practitioners, Rev 01/01/2015;

(e) Form DFS-F5-DWC-90/UB-04 CMS-1450, Uniform Bill, Rev. 11/03/2006; Completion Instructions for the DFS-F5-DWC-90, are comprised of four sets:

1. Form DFS-F5-DWC-90-A (UB-04), http://www.flrules.org/Gateway/reference.asp?No=Ref-06194, Completion Instructions for Hospitals, Rev. 12/08/2015;

2. Form DFS-F5-DWC-90-B (UB-04), http://www.flrules.org/Gateway/reference.asp?No=Ref-06195, Completion Instructions for Ambulatory Surgical Centers, Rev. 12/08/2015 (for dates of service on and after 07/08/2010);

3. Form DFS-F5-DWC-90-C (UB-04), http://www.flrules.org/Gateway/reference.asp?No=Ref-06196, Completion Instructions for Home Health Agencies, Rev. 12/08/2015;

4. DFS-F5-DWC-90-D (UB-04), http://www.flrules.org/Gateway/reference.asp?No=Ref-06197, Completion Instructions for Nursing Home Facilities, Rev. 12/08/2015.

(2) Obtaining Copies of Forms and Instructions.

(a) A copy of the Form DFS-F5-DWC-9 can be obtained from the AMA web site at https://commerce.ama-assn.org/store/. Completion instructions for the DFS-F5-DWC-9 can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(b) A copy of the Form DFS-F5-DWC-10 and completion instructions for the form can be obtained from the DFS/DWC website at: http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(c) A copy of the Form DFS-F5-DWC-11 can be obtained from the American Dental Association web site at http://www.ada.org/. Completion instructions for the form can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(d) A copy of the Form DFS-F5-DWC-25 and completion instructions can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(e) A copy of the instructions for completion of Form DFS-F5-DWC-90, Rev. 11/03/2006; Form DFS-F5-DWC-90-A (UB-04), Completion Instructions for Hospitals, Rev. 12/08/2015; Form DFS-F5-DWC-90-B (UB-04), Completion Instructions for Ambulatory Surgical Centers, Rev. 12/08/2015; Form DFS-F5-DWC-90-C (UB-04), Completion Instructions for Home Health Agencies, Rev. 12/08/2015; Form DFS-F5-DWC-90-D (UB-04), Completion Instructions for Nursing Home Facilities, Rev. 12/08/2015, can be obtained from the DFS/DWC website at http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm.

(3) Alternate Billing Form DFS-F5-DWC-10.

In lieu of submitting a Form DFS-F5-DWC-10 when billing for drugs or medical supplies, alternate billing forms are acceptable if:

(a) An insurer has approved the alternate billing form(s) prior to submission by a health care provider, and

(b) The form provides all information required to be submitted to the Division, pursuant to the Florida Medical EDI Implementation Guide (MEIG), on the Form DFS-F5-DWC-10, Form DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form for the DFS-F5-DWC-10.

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, 440.105(7), 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS. History–New 2-18-16.
Editorial Note: Formerly 69L-7.710(2).