Florida Regulations 59A-31.005

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§ 59A-31.005 Petition Requirements.

(1) All documents and records that support the allegations contained in the petition must accompany the petition. A petition that is accompanied by all items specified below will not be dismissed for failure to submit supporting documents and records:

(a) A copy of each Explanation of Bill Review received from the carrier providing notice of disallowance or adjustment of payment in this dispute.

(b) A copy of the medical bill or medical bills or request for reimbursement for which payment was disallowed or adjusted by the carrier on the contested Explanation of Bill Review(s).

(c) One copy set of all medical documentation and records submitted to the carrier in support of the medical bill(s) or request(s) for reimbursement which are the subject of this dispute.

(d) If the answer to question 5 on the Petition for Resolution of Reimbursement Dispute Form is yes, a copy of all applicable provision(s) of the reimbursement contract.

(e) Provider's documentation of authorization by carrier for non-emergency treatment for the date(s) of service covered by the petition.

(f) Documentation of health care provider notification to the carrier, pursuant to Section 440.13(3)(b), F.S., for emergency treatment for the date(s) of service included in the petition.

(2) If the petitioner does not submit a completed Petition for Resolution of Reimbursement Dispute Form, accompanied by all of the items specified in subsection 59A-31.005(1), F.A.C., the petitioner will be notified by the Agency of the deficiency in submission. The petitioner shall have ten (10) calendar days from receipt of the notice of deficiency to cure the deficiency by providing to the Agency the items specified in the Agency�s notice along with proof of proper service of the curative documentation upon the carrier. If the Agency does not receive the curative documentation and proof of service of the curative documentation upon the carrier within ten (10) days after petitioner's receipt of the notice of deficiency, the petition will be dismissed with prejudice.

(3) Documents and records accompanying the petition must be submitted in hard copy.

Specific Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7) FS. History: New 11-28-06.