RULE NO: RULE TITLE
69L-7.602: Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule
These changes are being made to address concerns expressed at the public hearing and in response to written comments received from the Joint Administrative Procedures Committee.
69L-7.602 Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule.
(1) Definitions. As used in this rule:
(a) through (t)(u) No change.
(u)(v) “Explanation of Bill Review” (EOBR) means the notice of payment or notice of adjustment, 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 subsection paragraph (5)(o) of this rule.
(v) through (ss) No change.
(2) Forms Incorporated by Reference for Medical Billing, Filing and Reporting.
(a) No change.
(b)2. Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Equipment & Supplies Form), Rev. 3/1/09 1/1/07. May be used to bill for dates of service up to and including 3/31/07 and shall be used to bill for dates of service on and after 4/1/07.
(c) through (d) No change.
(e)2. Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006); Form DFS-F5-DWC-90-B (Completion Instructions for Form DFS-F5-DWC-90 for use by hospitals), Rev. 1/1/09; 1/1/07. Form DFS-F5-DWC-90-C (Completion Instructions for Form DFS-F5-DWC-90 for use by Ambulatory Surgical Centers), New 1/1/09; Form DFS-F5-DWC-90-D (Completion Instructions for Form DFS-F5-DWC-90 for use by Home Health Agencies), New 1/1/09; FS-F5-DWC-90-E (Completion Instructions for Form DFS-F5-DWC-90 for use by Nursing Homes Facilities), New 1/1/09. May be used to bill for submissions between 3/1/07 and 5/22/07 and shall be used to bill for submissions on and after 5/23/07.
(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 AMA CMS web site: https:catalog.ama-assn.org/Catalog http://www.cms.hhs.gov/forms/. Completion instructions (DFS-F5-DWC-9-B) on of the form can be obtained from the Department of Financial Services/Division of Workers’ Compensation (DFS/DWC) web site: http://www.myfloridacfo.com/WC/forms.html http://www.fldfs.com/WC/forms.html#7.
2. through 4. No change.
5. A copy of either revision of the Form DFS-F5-DWC-90 can be obtained from the CMS web site: http://www.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. September 2006) and subparagraph (4)(b)4. of this rule. A copy of the Completion instructions for completion of Form DFS-F5-DWC-90 (Rev. 2006), Form DFS-F5-DWC-90-B (for hospitals) (Rev. 1/1/09 1/1/07), Form DFS-F5-DWC-90-C (for ASCs) (New 1/1/09), Form DFS-F5-DWC-90-D (for Home Health Agencies), Form DFS-F5-DWC-90-E (for Nursing Home Facilities), New 1/1/09, can be obtained from the DFS/DWC web site: http://www.myfloridacfo.com/WC/forms.html http://www.fldfs.com/WC/forms.html#7.
(g) No change.
(3) Materials Adopted by Reference. The following publications are incorporated by reference herein:
(a)(c) through (i)(k) No change.
(j)(l) National Uniform Billing Committee Official UB-04 Data Specifications Manual 20107, version 41.00, July 2009 September 2006, as adopted by the National Uniform Billing Committee. A copy of this manual can be obtained from the National Uniform Billing Committee web site: http://www.nubc.org/become.html http://www.nubc.org/UB-04%20SUBSCRIPTION%20ORDER%20FORM.doc.
(k)(m) The Florida Medical EDI Implementation Guide (MEIG), 20107, applicable for data submission on or after 4/2/07 and required for all data submission on or after 8/9/07. The Florida Medical EDI Implementation Guide (MEIG), 20107 can be obtained from the DFS/DWC web site: http://www.myfloridacfo.com/WC/edi_med.html http://www.fldfs.com/WC/edi_med.html.
(l) The Florida Workers’ Compensation Reimbursement Manual for Hospitals, Rule 69L-7.501, F.A.C.
(m) The Florida Workers’ Compensation Reimbursement Manual for Ambulatory Surgical Centers, Rule 69L-7.100, F.A.C.
(n) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C.
(4) Health Care Provider Responsibilities.
(a) Bill Submission/Filing and Reporting Requirements.
1. through 3. No change.
4. 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. No 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. through b. No change.
5. through 9. No change.
10. A health care provider shall bill multiple services, rendered on the same date of service, on a contiguous bill; provided however, nothing herein shall prevent a physician from selling, assigning or otherwise factoring a claim for the provision of pharmacy related services to a third party.
(b) Special Billing Requirements.
1. through 2. No change.
3. Recognized practitioners, except physician assistants, advanced registered nurse practitioners, certified registered nurse anesthetists, who are salaried employees of an authorized treating physician and 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 report and bill for such services on a Form DFS-F5-DWC-9 by entering the employing physician’s and enter his/her Florida Department of Health license number in Field 33b on the Form DFS-F5-DWC-9.;
4. through 5. No change.
6. Ambulatory Surgical Centers (ASCs) shall bill as follows:
a. For dates of service up to and including 07/07/2010, ASCs shall bill on a Form DFS-F5-DWC-9 using the American Medical Association’s CPT® procedure codes, or using the unique workers’ compensation unique procedure code 99070 with required modifiers and shall billing charges based on the ASC’s Charge Master except when billing for procedure code 99070.
b. For dates of service on or after 07/08/2010, Ambulatory Surgical Centers shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation unique code and the applicable CPT® or HCPCS modifer code in Form Locator 44 for each service rendered. ASCs shall bill charges based on the ASC’s Charge Master except when billing for surgical implants, associated disposable instrumentation and applicable shipping and handling. ASCs shall use Revenue Center Code 0278 and workers’ compensation unique code(s) with required modifier(s) pursuant to Rule 69L-7.100, F.A.C., when billing for surgical implants, associated disposable instrumentation, and applicable shipping and handling pursuant to Rule 69L-7.100, F.A.C. ASC medical bills shall be accompanied by all applicable documentation or certification required pursuant to Rule 69L-7.100, F.A.C.
7. Home Health Agencies (HHAs) shall bill on Form DFS-F5-DWC-90. Federal Facilities shall bill on their usual form.
a. For dates of service up to and including 07/07/2010, HHAs shall bill on letterhead or invoice.
b. For dates of service on or after 07/08/2010, HHAs shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation unique codes and the applicable CPT® or HCPCS modifier code in Form Locator 44 for each service rendered.
8. Nursing Home Facilities shall bill on Form DFS-F5-DWC-90. Out-of-State health care providers shall bill on the applicable medical bill form pursuant to paragraph (4)(c) of this rule.
a. For dates of service up to and including 07/07/2010, Nursing Home Facilities shall bill on letterhead or invoice.
b. For dates of service on or after 07/08/2010, Nursing Home Facilities shall bill on Form DFS-F5-DWC-90 and shall enter the CPT®, HCPCS or workers’ compensation unique code and the applicable CPT® or HCPCS modifier code in Form Locator 44 for each service rendered.
9. through 11. No change.
12. Pharmaceutical(s), Durable Medical Equipment and Home Medical Equipment or Supplies. 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.
a. No change.
I. No change.
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 segment separated by a dash (-). The workers’ compensation unique code DSPNS must be entered in addition to the NDC number in Field 24D. DME and medical supplies dispensed by a physician or recognized practitioner during an office visit must be billed on the DWC-9.
III. No change.
b. through h. No change.
13. through 15. No change.
(c) Bill Completion.
1. through 5. No change.
6. A An insurer can require a health care provider shall submit to complete additional data elements or supporting documentation that are not required by the insurer that have been requested in writing pursuant to paragraph (5)(b) of this rule. Division on Form DFS-F5-DWC-9 or DFS-F5-DWC-11.
(5) Insurer Responsibilities.
(a) No change.
(b) At the time of authorization for medical service(s) or upon receipt of notification of emergency care at the time a reimbursement request is received, an insurer shall notify each health care provider, in writing, of data elements additional form completion requirements or supporting documentation that are necessary for reimbursement determinations that are in addition to the requirements of this rule and the applicable reimbursement manual.
(c) through (v) No change.
(6) Insurer Electronic Medical Report Filing to the Division.
(a) through (d) No change.
(e) When filing any medical report replacement that corrects a rejected medical report bill or replaces a previously accepted medical report bill, the submitter shall use the same control number as the original submission. The replacement report submission shall contain all information necessary to process the medical report bill including all services and charges from the medical bill claim as billed by the health care provider and all payments made by the insurer to the health care provider. Additionally, an insurer or entity acting on behalf of an insurer shall follow the EDI medical bill replacement methodology specified in the 2010 Florida Medical EDI Implementation Guide (MEIG), using Report Reason Code “03” (See Appendix C), after being notified by the Division that data previously accepted has been deemed inaccurate and responding to a written request from the Division to review, correct, and re-submit accurate data. Each Division written request shall have a specified timeline to which the insurer or entity acting on behalf of an insurer shall adhere. Information contained on the original submission is deemed independent and is not considered as a supplement to information contained in the replacement submission.
(f) Each 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 “E” “D”, Form DFS-F5-DWC-10 Claim Detail Record Layout – Revision “E” “D”, Form DFS-F5-DWC-11 Claim Detail Record Layout – Revision “E” “D” and Form DFS-F5-DWC-90 Claim Detail Record Layout – Revision “E” “D” in accordance with the Florida Medical EDI Implementation Guide (MEIG), 20107, to the Division in accordance with the phase-in schedule as denoted below in subparagraphs 1., 2., and 3. of this section. The electronic record layout for Form DFS-F5-DWC-90 in the MEIG 2010 adds the new fields for Provider Facility National Provider Identification (NPI) number, Florida Agency for Health Care Administration facility license number for Ambulatory Surgical Centers, Home Health Care Agencies, and Nursing Home Facilities, procedure, service or supply code modifier 2 as billed by the provider, procedure, service or supply code modifier 3 as billed by the provider, procedure, service or supply code modifier 4 as billed by the provider, procedure, service or supply code as paid by the insurer, procedure, service or supply code modifier 1 as paid by the insurer, procedure, service or supply code modifier 2 as paid by the insurer, procedure, service or supply code modifier 3 as paid by the insurer, procedure, service or supply code modifier 4 as paid by the insurer, and the line item amount paid by the insurer. The electronic record layout for Form DFS-F5-DWC-9 in the MEIG, 2007, adds the new fields for gender, date of birth, up to three new modifiers and a maximum of three EOBR codes per line item from the revised code set. The electronic record layout for Form DFS-F5-DWC-10 in the MEIG, 2007, adds the new fields for gender, date of birth, pharmacist’s Florida Department of Health license number, and, medical supply and equipment HCPCS code(s), quantity, purchase or rental date, usual charge, amount paid, prescriber’s license number and a maximum of three EOBR codes per line item from the revised code set. The electronic record layout for Form DFS-F5-DWC-11 in the MEIG, 2007, adds the new fields for gender, date of birth and a maximum of three EOBR codes per line item from the revised code set. The electronic record layout for Form DFS-F5-DWC-90 in the MEIG, 2007, adds the new form locators for gender, date of birth, designation of surgery as scheduled or unscheduled, implant amount, up to three External Cause of Injury codes, four additional ICD-9 diagnostic codes, four other procedure codes, operating physician’s Florida DOH license number and a maximum of three EOBR codes per line item from the revised code set. 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 “D” “C”), between 04/01/2007 12/5/05 and 06/15/2007 2/24/06 shall begin testing on 03/01/2010 4/2/07 and shall complete the testing process with the new Revision “E” “D” record layouts no later than 04/12/2010 5/14/07.
2. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “D” “C”), between 06/16/2007 2/25/06 and 08/07/2007 3/31/06 shall begin testing on 04/13/2010 5/15/07 and shall complete the testing process with the new Revision “E” “D” record layouts no later than 05/25/2010 6/26/07.
3. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout – Revision “D” “C”), between 08/08/2007 4/1/06 and the effective date of this rule shall begin testing on 05/26/2010 6/27/07 and shall complete the testing process with the new Revision “E” “D” record layouts no later than 07/07/2010 8/8/07.
4. The Division will, resources permitting, allow submitters that volunteer to complete the test 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 Florida Workers’ Compensation Medical EDI Implementation Guide (MEIG), 20107.
(g) All submitters shall be in production with the new Revision “E” “D” record layouts on 07/08/2010 8/9/07. Optionally, after successful completion of the testing process and continuing up to and including 8/8/07, submitters may elect to submit all required medical reports as required in the new Revision “D” record layouts, as required in the current Revision “C” record layouts, or, as required in the Revision “C” record layouts for billings on the current medical claim forms and as required in the Revision “D” record layouts for billings on the new medical claim forms.
(h) No change.
(7) Insurer Administrative Penalties and Administrative Fines for Untimely Health Care Provider-Payment or Disposition of Medical Bills.
(a) The Department shall impose insurer administrative penalties for failure to comply with the payment, adjustment, disallowance or denial requirements pursuant to Section 440.20(6)(b), F.S. Timely performance standards for timely payments, adjustments and payments, disallowances or denials, reported on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90, shall be calculated and applied on a monthly basis for each separate form category that was received within a specific calendar month. Such insurer penalties shall be determined according to the penalty schedule in paragraph (7)(b) of this rule.
(b) No change.
The remainder of the reads as previously published.