69L-7.602: Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule
PURPOSE AND EFFECT: To adopt new 2007 versions of nationally approved uniform billing forms for medical providers which are utilized by Florida's Workers' Compensation insurance industry for medical bill reimbursements to healthcare providers, to adopt a revised pharmacy billing form, to amend the data reporting requirements resulting from medical form changes, to revise and add additional Explanation of Bill Review Codes used by insurers to report bill review outcomes to health care providers as required to facilitate the medical bill dispute resolution process, to update the Florida Workers' Compensation Medical EDI Implementation Guide (MEIG) reflecting its most current edition, and to update adopted reference material to reflect the most current edition.
SUBJECT AREA TO BE ADDRESSED: Rule amendment reflecting changes and updates to forthcoming national form changes and reporting methods.
SPECIFIC 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, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), 440.185(5), (9), 440.20 (6), 440.525(2), 440.593 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
TIME AND DATE: Monday, November 13, 2006, 10:00 a.m.
PLACE: 104 J Hartman Bldg., 2012 Capital Circle S.E., Tallahassee, FL
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Don davis, (850)413-1711. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Don Davis, Division of Workers' Compensation, Office of Data Quality and Collection, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4226, (850)413-1711.
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
69L-7.602
(1) No change.
(a) No change.
(b) “Adjust” or “Adjusted” means payment is made with modification to the information provided on the bill.
(c)(b) “Agency” means the Agency for Health Care Administration as defined in Section 440.02(3), F.S.
(d)(c) “
(e)(d) “Billing” means the process by which a health care provider submits a medical claim form or medical bill to an insurer, service company/third party administrator or any entity acting on behalf of the insurer, to receive reimbursement for medical services, goods, or supplies provided to an injured employee.
(f)(e) “Catastrophic Event” means the occurrence of an event outside the control of an insurer, submitter, service company/third party administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster, or an act of terrorism (including but not limited to cyber terrorism) or a telecommunications failure, in which recovery time will prevent an insurer, submitter, service company/third party administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and this rule. Programming errors, system malfunctions, or electronic data interchange transmission failures that are not a direct result of a catastrophic event are not considered to be a catastrophic event as defined in this rule. See paragraph (6)(d) for requirements to request approval of an alternative method and timeline for medical report filing with the Division due to a catastrophic event.
(g)(f) “Charges” means the dollar amount billed.
(h)(g) “Charge Master” means a comprehensive listing of all the supplies, goods and services for which the hospital or ambulatory surgical center maintains a separate charge with the hospital’s or ambulatory surgical center's charges for each of the supplies, goods and services, regardless of payer type. The charge master shall be maintained and produced when requested for the purpose of verifying its usual charges pursuant to Section 440.13(12)(d), F.S.
(i)(h) “Claims-Handling Entity File Number” means the number assigned to the claim file by the insurer or service company/third party administrator for purposes of internal tracking.
(j)(i) “Current Dental Terminology” (CDT) means the American Dental Association’s reference document containing descriptive terms to identify codes for billing and reporting dental procedures.
(k) “Current Procedural Terminology” (CPT®) means the American Medical Association’s reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services.
(l)(j) “Date Insurer Paid” or “Date Insurer Paid, Adjusted and Paid, Disallowed or Denied” means the date the insurer, service company/third party administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. If payment is disallowed or denied, “Date Insurer Paid” or “Date Insurer Paid, Adjusted and Paid, Disallowed or Denied” means the date the insurer, service company/third party administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits the appropriate notice of disallowance or denial to the health care provider or the health care provider representative. See paragraph (5)(l) for the requirement to accurately report the “date insurer paid”.
(m)(k) “Date Insurer Received” means the date that a Form DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic form equivalent is in the possession of the insurer, service company/third party administrator or any entity acting on behalf of the insurer. See paragraph (5)(l) for the requirement to accurately report the “date insurer received”. If a medical bill meets any of the criteria in (5)(j) of this rule and possession of the form is relinquished by the insurer, service company/TPA or any entity acting on behalf of the insurer by returning the medical bill to the provider with a written explanation for the insurer’s reason for return, then “date insurer received” shall not apply to the medical bill as submitted.
(n)(l) “Deny” or “Denied” means payment is not made because the service rendered is treatment for a non-compensable injury or illness. means to determine that no payment is to be made for a specific procedure code or other service reported by a health care provider to an insurer, service company/third party administrator or any entity acting on behalf of the insurer on a bill.
(o)(m) “Department” means Department of Financial Services (DFS) as defined in Section 440.02(12), F.S.
(p)(n) “Disallow” or “Disallowed” means payment is not made because the service rendered has not been substantiated for reasons of medical necessity, insufficient documentation, lack of authorization or billing error. means to determine that no payment is to be made for a specific procedure code or other service reported by a health care provider to an insurer, service company/third party administrator or any entity acting on behalf of the insurer for reimbursement, based on identification of a billing error, inappropriate utilization or over utilization, use of an incorrect billing form, only one line-item billed and the bill has an invalid code, or required information is inaccurate, missing or illegible.
(q)(o) “Division” means the Division of Workers’ Compensation (DWC) as defined in Section 440.02(14), F.S.
(r)(p) “Electronic Filing” means the computer exchange of medical data from a submitter to the Division in the standardized format defined in the Florida Medical EDI Implementation Guide (MEIG), 2006.
(s)(q) “Electronic Form Equivalent” means the format, provided in the Florida Medical EDI Implementation Guide (MEIG), 2006, to be used when a submitter electronically transmits required data to the Division. Electronic form equivalents do not include transmission by facsimile, data file(s) attached to electronic mail, or computer-generated paper-forms.
(t)(r) “Electronically Filed with the Division” means the date an electronic filing has been received by the Division and has successfully passed structural and data-quality edits.
(u)(s) “Entity” means any party involved in the provision of or the payment for medical services, care or treatment rendered to the injured employee, excluding the insurer, service company/third party administrator or health care provider as identified in this section.
(v)(t) “Explanation of Bill Review” (EOBR) means the notice of payment or notice of adjustment and payment, disallowance or denial sent by an insurer, service company/third party administrator or any entity acting on behalf of an insurer to a health care provider containing code(s) and code descriptor(s), in conformance with paragraph (5)(o) of this rule.
(w)(u) “Florida Medical EDI Implementation Guide (MEIG), 2006” is the Florida Division of Workers’ Compensation’s reference document containing the specific electronic formats and data elements required for insurer reporting of medical data to the Division.
(x)(v) “Healthcare Common Procedure Coding System National Level II Codes (HCPCS)” (HCPCS) means the Centers for Medicare and Medicaid Services’ (CMS) reference document listing descriptive codes for billing and reporting professional services, procedures, and supplies provided by health care providers.
(y)(w) “Health Care Provider” is defined in Section 440.13(1)(h), F.S.
(z)(x) “Hospital” is defined in Section 395.002(13), F.S.
(aa)(y) “ICD-9-CM International Classification of Diseases” (ICD-9) is the U.S. Department of Health and Human Services’ reference document listing the official diagnosis and inpatient-procedure code sets.
(bb)(z) “Insurer” is defined in Section 440.02(38), F.S.
(cc)(aa) “Insurer Code Number” means the number the Division assigns to each individual insurer, self-insured employer or self-insured fund.
(dd)(bb) “Itemized Statement” means a detailed listing of goods, services and supplies provided to an injured employee, including the quantity and charges for each good, service or supply.
(ee) “Medical Bill” means the document or electronic equivalent submitted by a health care provider to an insurer, service company/TPA or any entity acting on behalf of the insurer for reimbursement for services or supplies (e.g. DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider’s usual invoice or business letterhead) as appropriate pursuant to paragraph (4)(d) of this rule.
(ff)(cc) “Medically Necessary” or “Medical Necessity” is defined in Section 440.13(1)(l), F.S.
(gg)(dd) “NDC Nnumber” means the National Drug Code (NDC) number, assigned under Section 510 of the Federal Food, Drug, and Cosmetic Act, which identifies the drug product labeler/vendor, product, and trade package size. The NDC number is an eleven-digit number that is expressed in the universal 5-4-2 format and included on all applicable reports with each of the three segments separated by a dash (-).
(hh) “NPI” means the National Provider Identifier, a standard ten-digit numeric identifier assigned to each health care provider by the Centers for Medicare and Medicaid Services.
(ii) “Pay” or “Paid” means payment is made applying the applicable reimbursement formula to the medical bill as submitted.
(jj)(ee) “Physician” is defined in Section 440.13(1)(q), F.S.
(ff) “Physician’s Current Procedural Terminology (CPT®)” (CPT) means the American Medical Association’s reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services.
(kk)(gg) “Principal Physician” means the treating physician responsible for the oversight of medical care, treatment and attendance rendered to an injured employee, to include recommendation for appropriate consultations or referrals.
(ll)(hh) “Report” means any form related to medical services rendered, in relation to a workers’ compensation injury that, which is required to be filed with the Division under this rule.
(mm)(ii) “Service Company/Third Party Administrator (TPA)” means a party that has contracted with an insurer for the purpose of providing services necessary to adjust workers’ compensation claims on the insurer’s behalf.
(nn)(jj) “Service Company/Third Party Administrator (TPA) Code Number” means the number the Division assigns to a service company, adjusting company, managing general agent or third party administrator.
(oo)(kk) “Submitter” means an insurer, service company/TPA, entity or any other party acting as an agent or vendor on behalf of an insurer, service company/TPA or any entity to fulfill any insurer responsibility to electronically transmit required medical data to the Division.
(pp)(ll) “UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee, February 2006” (UB-92 Mmanual) is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992).
(qq) “UB-04, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee, January 2007” (UB-04 Manual) is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-04 HCFA-1450, Uniform Bill, Rev. 2006).
(2) Forms Incorporated by Reference for Medical Billing, Filing and Reporting.
(a)1. Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev. 12/90); Form DFS-F5-DWC-9-A (Completion Instructions for Form DFS-F5-DWC-9); comprised of three sets of completion instructions for use by health care providers, ambulatory surgical centers, and work hardening and pain management programs), Rev. 5/26/2005.; Effective to bill for dates of service up to and including 03/31/07.
2. Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Claim Form, Rev. 08/05); Form DFS-F5-DWC-9-B (Completion Instructions for Form DFS-F5-DWC-9: comprised of three sets of completion instructions for use by health care providers, ambulatory surgical centers, and work hardening and pain management programs), Rev. 1/1/2007. May be used to bill for dates of service up to and including 3/31/2007. Revision date 08/05 shall be used to bill for dates of service on and after 4/1/2007.
(b)1. Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form), Rev. 2/14/2006. Effective for dates of service up to and including 03/31/07.
2. Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form), Rev. 1/1/2007. Effective for dates of service on and after 4/1/2007.
(c)1. Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form, Rev. 2002); Form DFS-F5-DWC-11-A (Completion Instructions for Form DFS-F5-DWC-11), Rev. 5/26/2005. Effective to bill for dates of service up to and including 03/31/07.
2. Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form, Rev. 2006); Form DFS-F5-DWC-11-B (Completion Instructions for Form DFS-F5-DWC-11), Rev. 1/1/2007. May be used to bill for dates of service up to and including 3/31/2007. Revision date 1/1/2007 shall be used to bill for dates of service on and after 4/1/2007.
(d)1. Form DFS-F5-DWC-25 (; and
(e)1. Form DFS-F5-DWC-90 (UB-92 HCFA-1450, Uniform Bill, Rev. 1992). Effective for dates of service up to and including 05/22/07 are hereby incorporated by reference into this rule.
2. Form DFS-F5-DWC-90 (UB-04 HCFA-1450, Uniform Bill, Rev. 2006). May be used to bill for dates of service up to and including 3/31/2007. Revision date 2006 shall be used to bill for dates of service on and after 4/1/2007.
(f) Obtaining Copies of Forms and Instructions.
1. A copy of either revision of the Form DFS-F5-DWC-9 can be obtained from the CMS web site: http://www.cms.hhs.gov/forms/. Completion instructions for either revision of the form can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) web site: http://www.fldfs.com/ WC/forms.html#7.
2. A copy of either revision of the Form DFS-F5-DWC-10 and completion instructions for either revision of the form can be obtained from the DFS/DWC web site: http://www.fldfs. com/WC/forms.html#7.
3. A copy of either revision of the Form DFS-F5-DWC-11 can be obtained from the American Dental Association web site: http://www.ada.org/. Completion instructions for either revision of the form can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.
4. A copy of the Form DFS-F5-DWC-25 and completion instructions can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/forms.html#7.
5. A copy of either revision of the Form DFS-F5-DWC-90 can be obtained from the CMS web site: http://cms.hhs.gov/forms/. Completion instructions for Form DFS-F5-DWC-90 (Rev. 1992) can be obtained from the UB-92, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. February 2006) and subparagraph (4)(d)4. of this rule. Completion instructions for Form DFS-F5-DWC-90 (Rev. 2006) can be obtained from the UB-04, National Uniform Billing Data Element Specifications as Adopted by the Florida State Uniform Billing Committee (Rev. January 2007) and subparagraph (4)(d)4. of this rule.
(g)(b) In lieu of submitting a Form DFS-F5-DWC-10, when billing for drugs or medical supplies, alternate billing forms are acceptable if:
1. An insurer has approved the alternate billing form(s) prior to submission by a health care provider, and
2. The form provides all information required to be submitted to the Division, pursuant to the date-applicable Florida Medical EDI Implementation Guide (MEIG), 2006, on the Form DFS-F5-DWC-10. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form.
(3) Materials Adopted for Reference. The following publications are incorporated by reference herein:
(a) UB-92, National Uniform Billing Data Element Specifications as Adopted by the
(b) The Florida Medical EDI Implementation Guide (MEIG), 2006, applicable for data submission until 7/1/2007. The Florida Medical EDI Implementation Guide (MEIG), 2006 can be obtained from the DFS/DWC web site: http://www.fldfs.com/WC/edi_med.html.
(c) The American Medical Association Healthcare Common Procedure Coding System, Medicare’s National Level II Codes (HCPCS), as adopted in Rule 69L-7.020, F.A.C.
(d) The Physicians’ Current Procedural Terminology (CPT®), as adopted in Rule 69L-7.020, F.A.C.
(e) The Current Dental Terminology (CDT-4), as adopted in Rule 69L-7.020, F.A.C.
(f) The 20076 ICD-9-CM Professional for Hospitals, Volumes 1, 2 and 3, International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 20065, Ingenix, Inc. American Medical Association.
(g) The Physician ICD-9-CM 20076, Volumes 1 & 2, International Classification of Diseases, 9th Revision, Clinical Modification, Copyright 20065, Ingenix, Inc. (American Medical Association).
(h) The American Medical Association’s Guide to the Evaluation of Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C.
(i) The Minnesota Department of Labor and Industry Disability Schedule, as adopted in Rule 69L-7.604, F.A.C.
(j) The Florida Impairment Rating Guide, as adopted in Rule 69L-7.604, F.A.C.
(k) The 1996 Florida Uniform Permanent Impairment Rating Schedule, as adopted in Rule 69L-7.604, F.A.C.
(l) UB-04, National Uniform Billing Data Element Specifications as Adopted by the
(m) The
(4) Health Care Provider Responsibilities.
(a) Bill Submission/Filing and Reporting Requirements.
1. All providers are responsible for meeting their obligations, under this rule, regardless of any business arrangement with any entity under which claims are prepared, processed or submitted to the insurer.
2. Each health care provider must bill all services rendered on a single day, specifically an in-office medical service and dispensed medication, on a single billing form.
3.(b) Each health care provider is responsible for submitting any additional form completion information and supporting documentation requested, in writing, by the insurer at the time of authorization, or at the time a reimbursement request is received.
4. Each health care provider shall resubmit a medical claim form or medical bill with insurer requested documentation when the EOBR provides an explanation for disallowance based on the lack of documentation submitted with the medical bill.
5.(c) Insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of the injured employee’s medical treatment/status. Any other reporting forms may not be used in lieu of or supplemental to the Form DFS-F5-DWC-25. Provider failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the Form DFS-F5-DWC-25 Completion/Submission Instructions adopted in this rule, may result in the Agency imposing sanctions or penalties pursuant to subsection 440.13(8), F.S. or subsection 440.13(11), F.S.
a.1. The Form DFS-F5-DWC-25 does not replace physician notes, medical records or Ddivision-required medical billing reports.
b.2. All information submitted on physician notes, medical records or Ddivision-required medical billing reports must be consistent with information documented on the Form DFS-F5-DWC-25.
6. All medical claim form(s) or medical bill(s) related to services rendered for a compensable injury shall be submitted by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, as a requirement for billing.
7. Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, provided the insurer agrees.
8. When submitting a medical claim form or bill to the insurer, service company/TPA or any entity acting on behalf of the insurer, the health care provider must submit documentation that supports the medical necessity of services rendered and any required documentation pursuant to subsection (4)(b) of this rule and the applicable reimbursement manual
9. All medical claim forms or medical bills(s) submitted by a health care provider shall report charges at the health care provider’s usual charge for services, regardless of payer. The health care provider shall not report charges at an amount expected for reimbursement, at an amount expected following adjustment, at an amount specified in a contract, at an amount specified in a managed care arrangement or at any other amount which represents expected payment.
10. Each health care provider is responsible for correcting and resubmitting any billing forms returned by an insurer, service company/TPA or any entity acting on behalf of the insurer pursuant to paragraph (5)(j) of this rule.
(b)(d) Special Billing Requirements.
1. When anesthesia services are billed on a Form DFS-F5-DWC-9, completion of the form must include the CPT® code and the “P” code (physical status modifier), which correspond with the procedure performed, in Field 24D. Anesthesia health care providers shall enter the date of service and the 5-digit qualifying circumstance code, which correspond with the procedure performed, in Field 24D on the next line, if applicable.
2. When an Advanced Registered Nurse Practitioner (ARNP) provides services as a Certified Registered Nurse Anesthetist, the ARNP he/she shall bill on a Form DFS-F5-DWC-9 for the services rendered and enter his/her Florida Department of Health ARNP license number in Field 33, regardless of the employment arrangement under which the services were rendered, or the party submitting the bill.
3. Regardless of the employment arrangement under which the services are rendered or the party submitting the bill, the following health care providers, who render direct billable services for which reimbursement is sought from an insurer, service company/TPA or any entity acting on behalf of the insurer, service company/TPA, shall bill on a Form DFS-F5-DWC-9 and enter his/her Florida Department of Health license number in Field 33 on the Form DFS-F5-DWC-9:
a. through c. No change.
4. No change.
a. Inpatient billing – Hospitals shall, in addition to filing a Form DFS-F5-DWC-90:,
I. Aattach an itemized statement with charges based on the facility’s Charge Master; and
II. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501 F.A.C.; and
III. Bill professional services provided by a physician, physician assistant, advanced registered nurse practioner, or registered nurse first assistant on the Form DFS-F5-DWC-9 regardless of employment arrangement.
b. Outpatient billing – Hospitals shall:
I. iIn addition to filing a Form DFS-F5-DWC-90:,
I. Eenter the CPT®, HCPCS or unique workers’ compensation code (provided in the Florida Workers’ Compensation Health Care Provider Reimbursement Manual adopted in Rule 69L-7.020, F.A.C.) in Form Locator 44 on the Form DFS-F5-DWC-90, to bill outpatient radiology, clinical laboratory and physical, occupational or speech therapy charges; and
II. Make written entry “scheduled” or “non-scheduled” in Form Locator 84 of Form Rev. 1992 and in Form Locator 80 of Form Rev. 2006 – ‘Remarks’ on the DFS-F5-DWC-90, directly after entry of the hospital’s physical location ZIP code, when billing outpatient surgery or outpatient surgical services; and
III. Make written entry “implant(s)” followed by the maximum reimbursement allowance pursuant to Rule 69L-7.501, F.A.C., in Form Locator 84 of Form revision 1992 and in Form Locator 80 of Form revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90, directly after entry of “scheduled” or “non-scheduled”, when present, and otherwise directly after the hospital’s physical location ZIP code.
IV.III. Attach an itemized statement with charges based on the facility’s Charge Master if there is no line item detail shown on the Form DFS-F5-DWC-90; and
V. Submit all applicable documentation or certification required pursuant to Rule 69L-7.501 F.A.C.
VI. Bill professional services provided by a physician, physician assistant, advanced registered nurse practioner, or registered nurse first assistant on the Form DFS-F5-DWC-9 regardless of employment arrangement,
5. A cCertified, licensed physician assistants, anesthesia assistants and registered nurse first assistants who provides services as a surgical assistant, in lieu of a second physician, shall bill on a Form DFS-F5-DWC-9 entering the CPT® code(s) plus modifier(s), which represent the service(s) rendered, in Field 24D, and must enter his/her Florida Department of Health license number in Field 33.
6. Ambulatory Surgical Centers (ASCs) shall bill on a Form DFS-F5-DWC-9 with itemized line-item charges based on the ASC’s Charge Master. ASC medical bills shall be accompanied by all applicable documentation required pursuant to Rule 69L-7.100, F.A.C.
7. Federal Facilities shall bill on their usual form.
8. Out-of-State health care providers shall bill on the applicable medical bill form pursuant to paragraph (c) of this rule.
9.8. Dental Services.
a. No change.
b. No change.
10.9. Pharmaceutical(s), Durable Medical Equipment and Medical Supplies.
a. When supplying commercially available medicinal drugs commonly known as legend or prescription drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in Field 9, with each of the segments separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the NDC number, in the universal 5-4-2 format, in Field 24D, with each of the segments separated by a dash (-). Optionally, the unique workers’ compensation code 96370 may be entered in addition to the NDC number in Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
IV. Ambulatory Surgical Centers shall not separately bill for these products that are provided as a part of facility services:
b. When supplying medicinal drugs which are compounded and the prescribed formulation is not commercially available:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the unique workers’ compensation code 96371 in Field 9.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9 and shall enter the unique workers’ compensation code 96371 in form Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
IV. Ambulatory Surgical Centers shall not separately bill for these products that are provided as part of the facility’s services.
c. When supplying over-the-counter drug products:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format in form Field 9, with each of the segments separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the NDC number in the universal 5-4-2 format, in Field 24D, with each of the segments separated by a dash (-) and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
IV. Ambulatory Surgical Centers shall not separately bill for these products that are provided as part of the facility’s services.
d. When administering or supplying injectable drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each of the segments separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the appropriate revenue codes.
IV. Ambulatory Surgical Centers shall not separately bill for these products that are provided as part of the facility’s services.
e. When providing durable medical equipment (DME):
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/2005 and in Field 19 on form revision 1/1/2007.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable revenue codes.
IV. Ambulatory Surgical Centers shall bill for these products using applicable HCPCS codes.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in form Field 16 on form revision 2/14/2005 and in Field 19 on form revision 1/1/2007.
f. When providing medical supplies which are not incidental to a service or procedure:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/2005 and in Field 19 on form revision 1/1/2007.
II. Physicians, physician assistants or ARNPs shall bill on Form DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling.
III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable revenue codes.
IV. Ambulatory Surgical Centers shall bill separately for these products and shall enter the applicable HCPCS code in Field 24D.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall enter the applicable HCPCS code in Field 16 on form revision 2/14/2005 and in Field 19 on form revision 1/1/2007.
g. Pharmacists who provide Medication Therapy Management Services shall bill for these services on a Form DFS-F5-DWC-9 by entering the appropriate CPT® code(s) 0115T, 0116T or 0117T that represent the service(s) rendered in form Field 24D and shall enter their Florida Department of Health license number in Field 33 and shall submit a copy of the physician’s written prescription with the medical bill.
h. Pharmacists and medical suppliers may only bill on an alternate to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be approved for use as the alternate form.
a. Pharmacists and medical suppliers shall bill on a Form DFS-F5-DWC-10 or on an insurer pre-approved alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90 shall not be submitted as an alternate form.
b. Pharmacists shall complete Field 9, on a Form DFS-F5-DWC-10, by entering the unique workers’ compensation code 96371 when medicinal drugs are compounded and the formulation prescribed is not commercially available.
c. Dispensing physicians, physician assistants or ARNPs shall bill on a Form DFS-F5-DWC-9, when supplying commercially available medicinal drugs (commonly known as legend or prescription drugs) and shall enter the NDC number in Field 24D. Optionally, the unique workers’ compensation code 96370 may be entered in addition to the NDC code, in Field 24D.
d. When administering or supplying injectable drugs, the physician, physician assistant or ARNP shall bill on a Form DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in Field 24D.
e. Dispensing physicians shall complete Field 24D, on a Form DFS-F5-DWC-9, by entering the unique workers’ compensation code 96371 when medicinal drugs are compounded and the formulation prescribed is not commercially available.
f. Dispensing physicians, physician assistants or ARNPs shall bill by entering code 99070 in Field 24D, on a Form DFS-F5-DWC-9, when supplying over-the-counter drugs and shall submit documentation indicating the name, dosage, package size and cost of the drug(s).
g. Physicians and other licensed health care providers providing medical supplies shall bill on a Form DFS-F5-DWC-9 and attach documentation indicating the actual cost of the supply, including applicable manufacturer’s shipping and handling.
11.10. Physicians billing for a failed appointment for a scheduled independent medical examination (when the injured employee does not report to the physician office as scheduled) shall bill on their invoice or letterhead. The invoice shall not be a Form DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-DWC-90.
12.11. Health care providers receiving reimbursement under any payment plan (pre-payment, prospective pay, capitation, etc.) must accurately complete the Form DFS-F5-DWC-9 and submit the form to the insurer.
13.12. Health care providers and other insurer-authorized providers rendering services reimbursable under workers’ compensation, whose billing requirements are not otherwise specified in this rule (e.g. home health agencies, independent non-hospital based ambulance services, air-ambulance, emergency medical transportation, non-emergency transportation services, translation services, etc.) shall bill on their invoice or business letterhead. These providers shall not submit the Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.
(c)(e) Bill Completion.
1. Bills shall be legibly and accurately completed by all health care providers, regardless of location or reimbursement methodology, as set forth in this section and subsection (4)(b) of this rule.
2. Billing elements required by the Division to be completed by a health care provider are identified in specific Form DFS-F5-DWC-9-A or Form DFS-F5-DWC-9-B (completion instructions), as appropriate for the date of the revised form, available at the following websites:
a. http://www.fldfs.com/wc/pdf/DWC-9instrHCP.pdf when submitted by Licensed Health Care Providers;
b. http://www.fldfs.com/wc/pdf/DWC-9instrASC.pdf when submitted by Ambulatory Surgical Centers;
c. http://www.fldfs.com/wc/pdf/DWC-9instrWHPM.pdf when submitted by Work Hardening and Pain Management Programs.
3. Billing elements required by the Division to be completed for Pharmaceutical or Medical Supplier Billing are identified in specific Form DFS-F5-DWC-10 (completion instructions), as appropriate for the date of the revised form, available at website: http://www.fldfs.com/WC/forms.html#7.
4. Billing elements required by the Division to be completed for Dental Billing are identified in specific Form DFS-F5-DWC-11-A or Form DFS-F5-DWC-9-B (completion instructions), as appropriate for the date of the revised form, available at website: http://www.fldfs.com/WC/forms.html#7.
5. Billing elements required by the Division to be completed for Hospital Billing are identified in the UB-92 Manual, the UB-04 Manual and subparagraph (4)(b)(d)4. of this rule.
6. An insurer can require a health care provider to complete additional data elements that are not required by the Division on Forms DFS-F5-DWC-9 or DFS-F5-DWC-11.
(f) Health Care Provider Bill Submission/Filing and Reporting Requirements.
1. All medical claim form(s) or bill(s) related to services rendered for a compensable injury shall be submitted by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, as a requirement for billing.
2. Medical claim form(s) or bill(s) may be electronically filed or submitted via facsimile by a health care provider to the insurer, service company/TPA or any entity acting on behalf of the insurer, provided the insurer agrees.
3. Medical claim form(s) or bill(s) shall be filed by the health care provider with an insurer, service company/TPA or any entity acting on behalf of the insurer. The health care provider must submit required documentation that supports the medical necessity of services rendered. This requirement does not apply to Pharmacies, Medical Suppliers,
(5) Insurer Responsibilities.
(a) through (b) No change.
(c) At the time of authorization for medical service(s), an insurer shall inform in-state and an out-of-state health care providers of the specific reporting, billing and submission requirements of this rule and the specific address for submitting a reimbursement request.
(d) No change.
(e) Required data elements on each Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, and DFS-F5-DWC-90, for both medical only and lost-time cases, shall be filed with the Division within 45-calendar days of insurer, service company/TPA or any entity acting on behalf of the insurer, payment, adjustment and payment, disallowance or denial. Theis 45-calendar day filing requirement includes initial submission and correction and re-submission of all errors identified in the “Medical Claim Processing Report”, as defined in the date-applicable Florida Medical EDI Implementation Guide (MEIG), 2006.
(f) An insurer shall be responsible for accurately completing required data filed with the Division, as of the effective date of this rule, pursuant to the date-applicable Florida Medical EDI Implementation Guide (MEIG), 2006, and subparagraphs (4)(c)(e)2.-5. of this rule.
(g) No change.
(h) An insurer, service company/TPA or any entity acting on behalf of an insurer must report to the Division the procedure code(s), number of line-items billed, diagnosis code(s), or modifier code(s) and or amount(s) charged, as billed by the health care provider when reporting these data to the Division. An insurer shall file with the Division each individual bill submitted by a health care provider and shall not combine multiple bills received from a health care provider into a single medical bill data submission. However, the insurer, service company/TPA or any entity acting on behalf of an insurer may correct the procedure code(s) or modifier code(s) to effect payment and shall report both the provider billed code(s) and insurer adjusted code(s) pursuant to the date-appropriate MEIG. The insurer, service company/TPA or any entity acting on behalf of an insurer shall utilize the EOBR code “80” to notify the health care provider concerning any such billing errors and shall transmit EOBR code “80”, in instances when the carrier corrects the provider coding, when reporting to the Division.
(i) An insurer, service company/TPA or any entity acting on behalf of the insurer shall manually or electronically date stamp accurately completed Forms DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic form equivalent on the “date insurer received” as defined in paragraph (1)(m.k.) of this rule.
(j)1. When a medical bill is submitted for reimbursement by a health care provider, the insurer, service company/TPA or entity acting on behalf of the insurer must review the medical bill to determine if any of the criteria in subparagraph (5)(j)5. of this rule are present. If a medical bill meets any of the criteria listed in subparagraph (5)(j)5. of this rule, the insurer, service company/TPA or entity acting on behalf of the insurer must either:
a. Correct the information on the medical bill and proceed to make a reimbursement decision to pay, adjust, disallow or deny billed charges within 45-calendar days from the “date insurer received”; or
b. Return the medical bill to the provider with a written statement identifying the criteria under which the medical bill is being returned within twenty-one (21) days of the date insurer received. The written statement sent to the provider with the returned medical bill shall bear the following statement CAPITALIZED and in BOLD print: “A HEALTH CARE PROVIDER MAY NOT BILL THE INJURED EMPLOYEE FOR SERVICES RENDERED FOR A COMPENSABLE WORK-RELATED INJURY”.
2. If the insurer returns a medical bill to the provider pursuant to subparagraph (5)(j)5. of this rule, the written statement must include all criteria upon which the return of the medical bill are based.
3. If the criterion upon which the return of the medical bill is based includes any of the criteria in sub-subparagraph (5)(j)5.d.-f .of this rule, the written statement must identify the information that is illegible, incorrect, or omitted.
4. An insurer may return a medical bill to a provider without issuance of an EOBR only on the basis of the criteria set forth in subparagraph (5)(j)5. of this rule.
5. The criteria upon which a medical bill is to be reviewed by the insurer, service company/TPA or entity acting on behalf of the insurer for return pursuant to this sub-paragraph of paragraph (5)(j) of this rule are:
a. Services are billed on an incorrect medical billing form; or
b. The medical bill has been submitted to the incorrect insurer; or
c. The medical bill has been submitted to the incorrect service company/TPA or entity acting on behalf of the insurer; or
d. Claimant identification information required by this rule is illegible on the medical bill; or
e. Claimant identification information required by this rule is incorrect on the medical bill; or
f. Billing information required by this rule is omitted on the medical bill.
6. An insurer, service company/TPA or entity acting on behalf of the insurer shall establish and maintain a process by which medical bills that have been returned and written statements identifying the reason for return are compiled. The compiled information must be sufficiently detailed to allow verification and review by the Division.
An insurer, service company/TPA or any entity acting on behalf of the insurer shall return any bills to the provider, with a written explanation, when:
1. Services are billed on an incorrect billing form; or
2. An invalid code is used or a required code is omitted and is the only line-item billed on the form; or
3. Required billing information is illegible, inaccurate, or omitted on the form.
(k) An insurer, service company/TPA or any entity acting on behalf of the insurer shall pay, adjust and pay, disallow or deny billed charges within 45-calendar days from the date insurer received, pursuant to Section 440.20(2)(b), F.S.
(l) No change.
1. No change.
a. through d. No change.
2. The insurer must:
a. Ddocument the option(s) selected in subparagraph (5)(l)1. of this rule, must identify.
b. Document the specific effective date for each option selected, must specify.
c. Document the specific role of each “entity” acting on the insurers behalf in the option selected, and must.
d. Mmake this written documentation available to the Division for audit purposes pursuant to Section 440.525, F.S., When the insurer selects options b., c., or d. from subparagraph (5)(l)1. of this rule, there must be.
e. Maintain written documentation from the “entity” acknowledging its responsibilities concerning “date insurer received” and “date insurer paid” for each option. when the insurer selects options b., c., or d. from subparagraph (5)(l)1. of this rule, and The
f. Maintain written documentation maintained by the insurer must identifying the applicability of the options selected in sufficient detail to allow verification of the coding of each medical bill under subparagraph (5)(l)4. of this rule.
3. No change.
4. The option in subparagraph (5)(l)1. of this rule selected by the insurer must be identified on each medical report electronic submission to the Division, in accordance with paragraph (6)(e) of this rule, and must utilize the following coding methodology:
a. If the “date insurer received” is the date the insurer gains possession of the health care provider’s medical bill and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 1 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the date-appropriate Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x” 1 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(u)(s) of this rule is involved in the medical bill claims-handling processes related to “date insurer received” or “date insurer paid”.
b. If the “date insurer received” is the date the “entity” acting on behalf of the insurer gains possession of the health care provider’s medical bill and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the “entity” acting on behalf of the insurer, then Payment Code “x” 2 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the date-appropriate Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x” 2 to the Division, the insurer is declaring that the specified “entity” is acting on behalf of the insurer for purposes of the medical bill claims-handling processes related to “date insurer received” and ”date insurer paid”.
c. If the “date insurer received” is the date the insurer gains possession of the health care provider’s medical bill and “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the “entity” acting on behalf of the insurer, then Payment Code “x” 3 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the date-appropriate Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x” 3 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(u)(s) of this rule is involved in the medical bill claims-handling process related to “date insurer received”.
d. If the “date insurer received” is the date the “entity” acting on behalf of the insurer gains possession of the health care provider’s medical bill and the “date insurer paid” is the date the health care provider’s payment is mailed, transferred or electronically transmitted by the insurer, then Payment Code “x” 4 must be transmitted on each individual form-type electronic submission. (“x” must equal ‘R’, ‘M’ or ‘C’ as denoted in Appendix D of the date-appropriate Florida Medical Implementation EDI Guide (MEIG), 2006.) When submitting Payment Code “x” 4 to the Division, the insurer is declaring that no “entity” as defined in paragraph (1)(us) is involved in the medical bill claims-handling processes related to “date insurer paid”.
(m) An insurer, service company/TPA or any entity acting on behalf of the insurer, when reporting paid medical claims data to the Division, shall report the dollar amount paid by the insurer or reimbursed to the employee, the employer or other insurer for healthcare service(s) or supply(ies). When reporting disallowed or denied charges, the dollar amount paid shall be reported as $0.00.
(n) No change.
(o) In completing an Explanation of Bill Review (EOBR) an insurer shall, for each line item billed, select the EOBR code from the list below which identifies the reason for the insurer’s reimbursement decision for each line item. The insurer shall utilize only one EOBR code for each line item billed. The insurer shall utilize the EOBR code that most precisely describes the basis for its reimbursement decision. An insurer, service company/TPA or any entity acting on behalf of the insurer shall submit to the Division the Explanation of Bill Review (EOBR) code, relating to the adjudication of each line item billed.
The EOBR code list is as follows:
10 – Payment denied: compensability: injury or illness for which service was rendered is not compensable.
21 – Payment disallowed: medical necessity: medical records reflect no physician’s order was given for service rendered or supply provided.
22 – Payment disallowed: medical necessity: medical records reflect no physician’s prescription was given for service rendered or supply provided.
23 – Payment disallowed: medical necessity: diagnosis does not support the service rendered.
24 – Payment disallowed: medical necessity: service rendered was not therapeutically appropriate.
25 – Payment disallowed: medical necessity: service rendered was experimental, investigative or research in nature.
26 – Payment disallowed: service rendered by healthcare practitioner outside scope of practitioner’s licensure.
30 – Payment disallowed: lack of authorization: no authorization given for service rendered.
40 – Payment disallowed: insufficient documentation: documentation does not substantiate the service billed was rendered.
41 – Payment disallowed: insufficient documentation: level of evaluation and management service not supported by documentation.
42 – Payment disallowed: insufficient documentation: intensity of physical medicine and rehabilitation service not supported by documentation.
43 – Payment disallowed: insufficient documentation: frequency of service not supported by documentation.
44 – Payment disallowed: insufficient documentation: duration of service not supported by documentation.
45 – Payment disallowed: insufficient documentation: fraud statement not provided pursuant to Section 440.105(7), F.S.
46 – Payment disallowed: insufficient documentation: required itemized statement not submitted with the medical bill.
47 – Payment disallowed: insufficient documentation: invoice not submitted for implant.
48 – Payment disallowed: insufficient documentation: invoice not submitted for supplies.
49 – Payment disallowed: insufficient documentation: invoice not submitted for medication.
50 – Payment disallowed: insufficient documentation: requested documentation not submitted with the medical bill.
51 – Payment disallowed: insufficient documentation: required DFS-F5-DWC-25 not submitted.
52 – Payment disallowed: insufficient documentation: supply(ies) incidental to the procedure.
53 – Payment disallowed: insufficient documentation: required operative report not submitted with the medical bill.
54 – Payment disallowed: insufficient documentation: required narrative report not submitted with the medical bill.
60 – Payment disallowed: billing error: service previously billed and processed on prior medical bill.
61 – Payment disallowed: billing error: same service billed multiple times on same date of service.
62 – Payment disallowed: billing error: incorrect procedure, modifier or supply code.
63 – Payment disallowed: billing error: service billed is integral component of another procedure code.
64 – Payment disallowed: billing error: service “not covered” under applicable workers’ compensation reimbursement manual.
65 – Payment disallowed: billing error: multiple providers billed on the same form.
71 – Payment adjusted: insufficient documentation: level of evaluation and management service not supported by documentation.
72 – Payment adjusted: insufficient documentation: intensity of physical medicine and rehabilitation service not supported by documentation.
73 – Payment adjusted: insufficient documentation: frequency of service not supported by documentation.
74 – Payment adjusted: insufficient documentation: duration of service not supported by documentation.
75 – Payment adjusted: insufficient documentation: requested documentation not submitted with the medical bill.
80 – Payment adjusted: billing error: correction of procedure, modifier or supply code.
81 – Payment adjusted: billing error: payment modified pursuant to a charge audit.
82 – Payment adjusted: payment modified pursuant to carrier charge analysis.
83 – Payment adjusted: medical benefits paid apportioning out the percentage of the need for such care attributable to preexisting condition (Section 440.15(5)(b), F.S.).
84 – Payment adjusted: co-payment applied pursuant to s.440.13(14)(c), F.S.
90 – Paid: no modification to the information provided on the medical bill: payment made pursuant to
91 – Paid: no modification to the information provided on the medical bill: payment made pursuant to
92 – Paid: no modification to the information provided on the medical bill: payment made pursuant to
93 – Paid: no modification to the information provided on the medical bill: payment made pursuant to contractual arrangement.
94 – Paid: Out-of-State Provider: payment made pursuant to the Out-of-State Provider section of the applicable
95 – Paid: Reimbursement Dispute Resolution: payment made pursuant to Agency determination on a Petition for Resolution of Reimbursement Dispute, pursuant to Section 440.13(7), F.S.
A submitter, filing electronically, shall submit to the Division the Explanation of Bill Review (EOBR) code(s), relating to the adjudication of each line item billed and:
1. Maintain the EOBR in a format that can be legibly reproduced, and
2. Use the EOBR codes and code descriptors as follows:
a. 01 Services not authorized, as required.
b. 02 Services denied as not related to the compensable work injury.
c. 03 Services related to a denied work injury: Form DFS-F2-DWC-12 on file with the Division.
d. 04 Services billed are listed as not covered or non-covered (“NC”) in the applicable reimbursement manual.
e. 05 Documentation does not support the level, intensity, frequency, duration or provision of service(s) billed. (Insurer must specify to the health care provider.)
f. 06 Location of service(s) is not consistent with the level of service(s) billed.
g. 07 Reimbursement equals the amount billed.
h. 08 Reimbursement is based on the applicable reimbursement fee schedule.
i. 09 Reimbursement is based on any contract.
j. 10 Reimbursement is based on charges exceeding the stop-loss point.
k. 11 Reimbursement is based on insurer re-coding. (Insurer must specify to the health care provider.)
l. 12 Charge(s) are included in the per diem reimbursement.
m. 13 Reimbursement is included in the allowance of another service. (Insurer must specify procedure to the health care provider.)
n. 14 Itemized statement not submitted with billing form.
o. 15 Invalid code. (Use only when other valid codes are present.)
p. 16 Documentation does not support that services rendered were medically necessary.
q. 17 Required supplemental documentation not filed with the bill. (Insurer must specify required documentation to the health care provider.)
r. 18 Duplicate Billing: Service previously paid, adjusted and paid, disallowed or denied on prior claim form or multiple billing of service(s) billed on same date of service.
s. 19 Required Form DFS-F5-DWC-25 not submitted within three business days of the first treatment pursuant to Section 440.13(4)(a), F.S.
t. 20 Other: Unique EOBR code descriptor. Use of EOBR code “20” is restricted to circumstances when an above-listed EOBR code does not explain the reason for payment, adjustment and payment, disallowance or denial of payment. When using EOBR code “20”, an insurer must reflect code “20” and include the specific explanation of the code on the EOBR sent to the health care provider. The insurer, service company/TPA or any entity acting on behalf of the insurer must maintain a standardized EOBR code descriptor list.
(p) An insurer, service company/TPA, submitter or any entity acting on behalf of the insurer shall make available to the Division and to the Agency, upon request and without charge, a legibly reproduced copy of the electronic form equivalents or Forms DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-25, DFS-F5-DWC-90, supplemental documentation, proof of payment, EOBR and standardized EOBR code “20” descriptor list, and the insurer written documentation required in subparagraph (5)(l)2. of this rule.
(q) An insurer, service company/TPA or any entity acting on behalf of the insurer to pay, adjust and pay, disallow or deny a filed bill shall submit to the health care provider an Explanation of Bill Review, utilizing the EOBR codes and code descriptors, as set forth in paragraph (o) of this section, and shall include the insurer name and specific insurer contact information. An insurer, service company/TPA or any entity acting on behalf of the insurer shall notify the health care provider of notice of payment or notice of adjustment and payment, disallowance or denial only through an EOBR. An EOBR shall specifically state that the EOBR constitutes notice of disallowance or adjustment of payment within the meaning of Section 440.13(7), F.S. An EOBR shall 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” for the purpose of receiving the petitioner’s service of a copy of a petition for reimbursement dispute resolution by certified mail, pursuant to Section 440.13(7)(a), F.S.
(r) Copies of hospital medical records shall be subject to charges allowed pursuant to Section 395.3025, F.S. and Section 440.13, F.S.
(s) An insurer, service company/TPA or any entity acting on behalf of the insurer renders pre-payment for medical services or pharmacy first-fill services, the required data elements including the pre-payment or first-fill indicator, shall be submitted to the Division within 45 days of the insurer, service company/TPA or any entity acting on behalf of the insurer receipt date of the medical billing form, regardless of the date of payment.
(6) No change.
(a) No change.
(b) Required data elements shall be submitted in compliance with the instructions and formats as set forth in the date-appropriate Florida Medical Implementation EDI Guide (MEIG), 2006.
(c) No change.
(d) Submitters who experience a catastrophic event resulting in the insurer’s failure to meet the reporting requirements in paragraph (5)(e) of this rule, shall submit a written or electronic request within 15 business days after of the catastrophic event failure to the Division for approval to submit in an alternative reporting method and an alternative filing timeline. The request shall contain a detailed explanation of the nature of the event, date of occurrence, and measures being taken to resume electronic submission. The request shall also provide an estimated date by which electronic submission of affected EDI filings will be resumed. Approval must be obtained from the Division’s Office of Data Quality and Collection, beyond the control of the submitter prevents electronic submission.
(e) When filing any medical report that corrects a rejected medical bill or replaces a previously accepted medical bill, the submitter shall use the same control number as the original submission. The replacement submission shall contain all information necessary to process the medical bill including all services and charges from the claim as billed by the health care provider and all payments made by the insurer to the health care provider. Information contained on the original submission is deemed independent and is not considered as a supplement to information contained in the replacement submission.
(f) Additionally, an insurer shall be responsible for accurately completing the electronic record-layout programming requirements for the reporting of the Form DFS-F5-DWC-9 Claim Detail Record Layout – Revision “D” and the Form DFS-F5-DWC-10 Claim Detail Record Layout – Revision “D”, Form DFS-F5-DWC-11 Claim Detail Record Layout – Revision “D” and Form DFS-F5-DWC-90 Claim Detail Record Layout – Revision “D” in accordance with the Florida Workers’ Compensation Medical Implementation Guide (MEIG), 2007, to the Division in accordance with the phase-in schedule as denoted below in sub-subparagraphs a., b., and c. of this section. The electronic record layout for Form DFS-F5-DWC-9 in the MEIG, 2007, adds the new fields for healthcare provider NPI, gender (sex) and date of birth. The electronic record layout for Form DFS-F5-DWC-10 in the MEIG, 2007, adds the new fields healthcare provider, pharmacist, pharmacy and medical supplier NPI, date of birth, gender (sex), and medical supply and equipment HCPCS code(s), quantity, purchase or rental date, usual charge, amount paid, prescriber’s license number and NPI. The electronic record layout for Form DFS-F5-DWC-11 in the MEIG, 2007, adds the new fields for NPI, gender (sex) and date of birth. The electronic record layout for Form DFS-F5-DWC-90 in the MEIG, 2007, adds the new form locators for attending physician NPI, hospital NPI, date of birth, gender (sex), implant amount and up to four addition diagnosis(es) codes. The conversion implementation schedule is as follows:
1. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “C”), between December 05, 2005 and February 24, 2006 shall begin testing on March 01, 2007 and shall be in production with the new record layouts no later than April 12, 2007,
2. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “C”), between February 25, 2006 and March 31, 2006 shall begin testing on April 13, 2007 and shall be in production with the new record layouts no later than May 18, 2007.
3. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “C”), between April 01, 2006 and the effective date of this rule shall begin testing on May 21, 2007 and shall be in production with the new record layouts no later than July 02, 2007.
4. The Division will, resources permitting, allow submitters that volunteer to complete test transmission to production transmission processes earlier than the schedule denoted above. Each voluntary submitter shall have six weeks to complete test transmission to production transmission processes, for all electronic form equivalents, that comply with requirements set forth in the
(e) Effective September 1, 2006, each insurer shall be responsible for accurately completing the additional electronic Revision C record-layout programming requirements in accordance with the Florida Medical EDI Implementation Guide (MEIG), 2006. The additional requirements include:
1. The electronic record layout in the Florida Medical EDI Implementation Guide (MEIG), 2006, for Form DFS-F5-DWC-10 adds the new Field 16B for submission of the Amount Paid by Insurer.
2. The electronic record layout in the Florida Medical EDI Implementation Guide (MEIG), 2006, amends the Payment Plan Code values in Appendix D for Field 23A on the Form DFS-F5-DWC-9, Field 24A on the Form DFS-F5-DWC-10, Field 24A on the Form DFS-F5-DWC-11, and Field 36A on the Form DFS-F5-DWC-90 in order to collect and specify the insurer’s particular medical bill claims-handling arrangements for “date insurer received” and for “date insurer paid, adjusted and paid, disallowed, or denied” for each individual medical bill form type. The data field name is changed from “Payment Plan Code” to “Payment Code” to reflect these modifications to the values.
3. The designation of the claims-handling arrangement affirms the option selected by the insurer in subparagraph (5)(l)1. of this rule.
(7) No change.
Specific 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, 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), 440.185(5), (9), 440.20 (6), 440.525(2), 440.593 FS. History–New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06,________.