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


Effective on Thursday, February 18, 2016
  • 1(1) The following forms, including form completion instructions, are incorporated for use with rules adopted under this rule chapter.

    20(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.

    391. Form DFS-F5-DWC-9-A, 42http://www.flrules.org/Gateway/reference.asp?No=Ref-06186, 44Completion Instructions for Physicians and Recognized Practitioners, Rev. 01/01/2015;

    532. Form DFS-F5-DWC-9-B, 56http://www.flrules.org/Gateway/reference.asp?No=Ref-06187, 58Completion Instructions for Work Hardening and Pain Management Programs, Rev. 01/01/2015;

    693. Form DFS-F5-DWC-9-C, 72http://www.flrules.org/Gateway/reference.asp?No=Ref-06188, 74Completion Instructions for Ambulatory Surgical Centers, Rev. 01/01/2015 (only for dates of services prior to July 8, 2010);

    92(b) Form DFS-F5-DWC-10, 95http://www.flrules.org/Gateway/reference.asp?No=Ref-06189, 97Statement of Charges for Drugs and Medical Equipment & Supplies Form, Rev. 01/01/2015; Form DFS-F5-DWC-10-A, 112http://www.flrules.org/Gateway/reference.asp?No=Ref-06190, 114Completion Instructions for Pharmacies and Home Medical Equipment Providers/Suppliers, Rev. 12/08/2015;

    125(c) Form DFS-F5-DWC-11, American Dental Association Dental Claim Form, Rev. 2012; Form DFS-F5-DWC-11-A, 138http://www.flrules.org/Gateway/reference.asp?No=Ref-06191, 140Completion Instructions for Dentists, Rev. 01/01/2015;

    146(d) Form DFS-F5-DWC-25, 149http://www.flrules.org/Gateway/reference.asp?No=Ref-06192, 151Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form, Rev. 1/31/2008; Form DFS-F5-DWC-25-A, 163http://www.flrules.org/Gateway/reference.asp?No=Ref-06193, 165Completion Instructions for Physicians and Recognized Practitioners, Rev 01/01/2015;

    174(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:

    1921. Form DFS-F5-DWC-90-A (UB-04), 196http://www.flrules.org/Gateway/reference.asp?No=Ref-06194, 198Completion Instructions for Hospitals, Rev. 12/08/2015;

    2042. Form DFS-F5-DWC-90-B (UB-04), 208http://www.flrules.org/Gateway/reference.asp?No=Ref-06195, 210Completion Instructions for Ambulatory Surgical Centers, Rev. 12/08/2015 (for dates of service on and after 07/08/2010);

    2263. Form DFS-F5-DWC-90-C (UB-04), 230http://www.flrules.org/Gateway/reference.asp?No=Ref-06196, 232Completion Instructions for Home Health Agencies, Rev. 12/08/2015;

    2404. DFS-F5-DWC-90-D (UB-04), 243http://www.flrules.org/Gateway/reference.asp?No=Ref-06197, 245Completion Instructions for Nursing Home Facilities, Rev. 12/08/2015.

    253(2) Obtaining Copies of Forms and Instructions.

    260(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.

    298(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.

    320(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.

    353(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.

    372(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.

    436(3) Alternate Billing Form DFS-F5-DWC-10.

    441In lieu of submitting a Form DFS-F5-DWC-10 when billing for drugs or medical supplies, alternate billing forms are acceptable if:

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

    479(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.

    521Rulemaking Authority 523440.13(4), 524440.15(3)(b), 525(d), 526440.185(5), 527440.525(2), 528440.591, 529440.593(5) FS. 531Law Implemented 533440.09, 534440.105(7), 535440.13(2)(a), 536(3), (4), (6), (11), (12), (14), (16), 543440.15(3)(b), 544(d), (5), 546440.185(5), 547(9), 548440.20(6), 549440.525(2), 550440.593 FS. 552History–New 2-18-16.
    554Editorial Note: Formerly 55769L-7.710(2).

     

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