69L-10.006: Definitions
69L-10.012: Review of Proof of Claim
69L-10.015: Deemed Denial - 120 Day Time Period
69L-10.016: Documenting Expenditures for Purposes of Obtaining Reimbursement
69L-10.017: Reimbursement to Subsequent Employer
69L-10.019: Forms
PURPOSE AND EFFECT: To revise forms to comply with Section 119.071(5), F.S. (2007), that precludes an agency from collecting an individual’s social security number unless such collection conforms to specified provisions of that statute. Forms SDF-1 (Proof of Claim), and SDF-2 (Reimbursement Request), incorporated by reference in Rule 69L-10.019, F.A.C., are renumbered, and amended so that the collection of the social security number is discontinued. Form SDF-6 (Explanation of Benefits), incorporated by reference in Rule 69L-10.016, F.A.C., is renumbered, and amended so that the collection of the social security number is discontinued. In lieu of social security numbers, the revised forms shall utilize an “SDTF Claim Number” for purposes of identifying and tracking claims. Rule 69L-10.017, F.A.C., is deleted, as there is no statutory authority for the reimbursements prescribed in the rule. In addition, Form SDF-5 (Claim for Reimbursement for Salary), incorporated by reference in Rule 69L-10.019, F.A.C., is deleted from the rule for the same reason. Finally, Rule 69L-10.006, F.A.C., is amended to reflect the renumbering of Form SDF-6 to DFS-F1-SDF-6. Rule 69L-10.012, F.A.C., and Rule 69L-10.015, F.A.C., are amended to reflect the renumbering of Form SDF-1 to DFS-F1-SDF-1 and to amend the rules specific authority. Rule 69L-10.016, F.A.C., is amended to reflect the renumbering of Form SDF-2 to DFS-F1-SDF-2 and also amends the rule’s specific authority.
SUBJECT AREA TO BE ADDRESSED: Revision of forms for renumbering and to eliminate the collection of social security numbers, and to amend specific authority; also deletes Rule 69L-10.017, F.A.C., and Form SDF-5 for lack of statutory authority.
SPECIFIC AUTHORITY: 440.49(2), (7), 440.591 FS.
LAW IMPLEMENTED: 440.49 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: Tuesday., November 4, 2008, 10:00 a.m.
PLACE: 104J Hartman Bldg., 2012 Capital Circle S.E., Tallahassee, Florida
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: Eric Lloyd at (850)413-1689. 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: Eric Lloyd, Manager, Special Disability Trust Fund, Division of Workers’ Compensation, Department of Financial Services, 200 East Gaines Street, Tallahassee, Florida 32399-4223, (850)413-1689
THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:
69L-10.006 Definitions.
(1) CLAIMANT – an insurance carrier, self-insurance fund, or employer seeking reimbursement from the SDTF.
(2) REPRESENTATIVE – a person representing a claimant such as an attorney or a service organization.
(3) NOTICE OF CLAIM – The document[s] submitted by a claimant that places the SDTF on notice of the claim.
(4) PROOF OF CLAIM – The document[s] submitted by a claimant that includes a completely filled out DFS Form DFS-F1-SDF-1SDF-1 (rev._______12/91) with all required documents attached to fully support the claim.
Specific Authority 440.49(2), 440.591 FS. Law Implemented 440.49 FS. History–New 4-19-92, Amended 8-18-93, Formerly 38F-10.006, 4L-10.006, Amended_________.
69L-10.012 Review of Proof of Claim.
The SDTF will not consider a claim ripe, or mature, for review purposes, until a Proof of Claim is filed complete with all the necessary documents required by DFS Form DFS-F1-SDF-1SDF-1 (Rev. ______12/91). If a Proof of Claim is placed in line for review and it is discovered that certain documents or required information have not been provided by the claimant, the SDTF will advise the claimant in writing of the incomplete claim and will not review the claim until the missing information or document has been supplied by the claimant.
Specific Authority 440.49(7), 440.591, 440.49(2)(g) FS. Law Implemented 440.49(2) FS. History–New 4-19-92, Formerly 38F-10.012, 4L-10.012, Amended_________.
69L-10.015 Deemed Denial – 120 Day Time Period.
The 120 days that the SDTF has to accept a claim after it has been filed begins to run at the time the SDTF receives a fully completed Proof of Claim on DFS Form DFS-F1-SDF-1SDF-1 (Rev. ______12/91). Upon receipt of said form the SDTF shall notify the claimant within twenty-one (21) days of receipt that said form is complete and contains the required documents. If the form is complete the 120 days begins to run. If it is not complete and the SDTF notifies the claimant within the twenty-one (21) day period, then the 120 days from notice of claim does not begin to run until the claimant submits all the required documents necessary to support the claim.
Specific Authority 440.49(7), 440.49(2)(g) FS. Law Implemented 440.49(2) FS. History–New 4-19-92, Formerly 38F-10.015, 4L-10.015, Amended_________.
69L-10.016 Documenting Expenditures for Purposes of Obtaining Reimbursement.
In order to obtain reimbursement after an offer of reimbursement has been extended by the Fund, an employer/carrier shall file with the Fund a Form DFS-F1-SDF-2SDF-2, as adopted in Rule 69L-10.019, F.A.C., with supporting schedules and documentation of expenditures as set forth below.
(1) Expenditures for Medical Benefits. Expenditures for medical benefits must be documented by the submission of applicable Division forms, as adopted in Rule 69L-3.025, F.A.C., showing compliance with the fee schedules adopted in Rule 69L-7.020, F.A.C., and applicable utilization review procedures such as medical bills marked “paid” or an EOB that was completed contemporaneously with the processing of the medical payments together with corroborating documentation of amount paid (e.g., computer printouts, ledger sheets, or copies of checks). The EOB shall be in the format prescribed by the Fund in DFS Form DFS-F1-SDF-6SDF-6, REV. ______8/98, which form is hereby adopted by reference. DFS form DFS-F1-SDF-6SDF-6 may be obtained from the SDTF at the address set out in Rule 69L-10.019, F.A.C. If the carrier is unable to provide the data on the forms adopted by this section they may submit their own version of an EOB provided that it contains all of the elements of the DFS-F1-SDF-6SDF-6. The SDTF shall request additional information documenting expenditures by health care providers if necessary to prove that the benefits requested for reimbursement are related to the injury and are required to be provided under Section 440.49, F.S. Computer printouts or ledger sheets are not acceptable forms of documenting expenditures for medical benefits unless accompanied by medical bills marked paid or an DFS-F1-SDF-6SDF-6 or its equivalent.
(2) Expenditures for Compensation Voluntarily Paid.
(a) When temporary or permanent disability compensation, permanent impairment benefits, or death benefits have been voluntarily paid, such benefits may be documented by Progress/Final Report, DFS DWC-13 forms, as adopted in Rule 69L-3.025, F.A.C., which were prepared contemporaneously with payment, or by copies of checks. If the DWC-13 forms were not prepared contemporaneously with the payment of compensation, computer printouts or ledger sheets may be used to corroborate the payment. However, in regard to each of these classes of benefits, if the total payment listed on the DWC-13 form, printout, or ledger for a particular class is greater than the rate of compensation multiplied by the number of calendar weeks in the period, copies of checks must be supplied to document expenditures.
(b) When wage-loss benefits have been voluntarily paid, such benefits shall be documented only by copies of checks or by copies of fully completed Request for Wage Loss/Temporary Partial Benefits, DWC-3 forms, as adopted in Rule 69L-3.025, F.A.C.
(3) Expenditures for Compensation Pursuant to Order. When temporary or permanent disability compensation, permanent impairment benefits, death benefits or wage-loss benefits have been paid pursuant to an order of the Judge of Compensation Claims, which has become final, payment can be documented by providing a copy of the order.
(4) Miscellaneous.
(a) Changes in the rate of compensation shall be established by Notice of Action/Change, DFS DWC-4 forms and by DFS DWC-13 forms, as adopted in Rule 69L-3.025, F.A.C., which set forth the number of weeks paid at each rate of compensation. If the DWC-13 forms were not prepared contemporaneously with payment, then computer printouts or ledger sheets may be used to corroborate the change in the compensation rate. Copies of checks are also a sufficient means of documenting changes in the rate of compensation.
(b) Changes in the class of benefits paid by the employer/carrier shall be documented by DFS DWC-4 forms which set forth the date that a prior category of benefits was terminated, as well as the date that a subsequent class of benefits was first paid.
Specific Authority 440.49(7), 440.49(2)(g), 440.591 FS. Law Implemented 440.49(2) FS. History–New 4-19-92, Amended 8-18-93, Formerly 38F-10.016, 4L-10.016, Amended_________.
69L-10.017 Reimbursement to Subsequent Employer.
(1) An employer may seek reimbursement pursuant to the provisions of paragraph 440.49(2)(k), Florida Statutes, which would reimburse the employer for hiring an employee who has incurred a permanent impairment from a Florida workers’ compensation injury and has been unemployed as a result of his injury for two (2) consecutive years after the date of accident.
(2) Any employer seeking reimbursement shall file a Claim For Reimbursement for Salary on DFS Form SDF-5 (12/91). The Claim for Reimbursement for Salary shall be filed within a six (6) month period from the date the employee is hired or the claim is forever barred.
(3) Any Claim for Reimbursement for Salary that is denied by the SDTF will be barred unless the claimant files an application for hearing with the Division within sixty (60) days after receipt of notice that their claim has been denied. The application for hearing shall be filed in the manner as provided by Section 440.49(2)(g), Florida Statutes.
Specific Authority 440.49(2)(k) FS. Law Implemented 440.49(2) FS. History–New 4-19-92, Formerly 38F-10.017, 4L-10.017, Repealed________.
69L-10.019 Forms.
The following forms are incorporated by reference into these rules and are available from and shall be filed with: SDTF, Division of Workers’ Compensation, 200 East Gaines Street, Tallahassee, FL 32399-4223.
(1) DFS Form DFS-F1-SDF-1SDF-1 – Proof of Claim (Rev. ______12/91).
(2) DFS Form DFS-F1-SDF-2SDF-2 – Reimbursement Request Request For Reimbursement (Rev. ______3/92).
(3) DFS Form SDF-5 – Claim For Reimbursement for Salary (9/91).
Specific Authority 440.49(7), 440.591 440.49(2)(g), 440.30 FS. Law Implemented 440.49(2) FS. History–New 4-19-92, Amended 8-18-93, Formerly 38F-10.019, 4L-10.019, Amended_________.