Florida Regulations 69L-7.602pt2

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§ 69L-7.602pt2 Florida Workers' Compensation Medical Services Billing, Filing and Reporting Rule (Part 2).

Editor's note: due to its length, this section has been divided into two sections. For the first half of the section, see 69L-7.602pt1.

(c) 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 paragraph (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, Form DFS-F5-DWC-90-B (completion instructions) and subparagraph (4)(b)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 Form DFS-F5-DWC-9 or DFS-F5-DWC-11.

(5) Insurer Responsibilities.

(a) An insurer is responsible for meeting its obligations under this rule regardless of any business arrangements with any service company/TPA, submitter or any entity acting on behalf of an insurer under which claims are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division.

(b) At the time of authorization for medical service(s) or at the time a reimbursement request is received, an insurer shall notify each health care provider, in writing, of additional form completion requirements or supporting documentation that are necessary for reimbursement determinations.

(c) At the time of authorization for medical service(s), an insurer shall inform in-state and out-of-state health care providers of the specific reporting, billing and submission requirements of this rule and provide the specific address for submitting a reimbursement request.

(d) Insurers, service company/TPAs or entities acting on behalf of insurers and health care providers shall utilize only the Form DFS-F5-DWC-25 for physician reporting of an 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.

(e) Required data elements on each Form 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 when the medical bill is paid, adjusted, disallowed or denied by the insurer, service company/TPA or any entity acting on behalf of the insurer. The 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).

(f) An insurer shall be responsible for accurately completing required data filed with the Division, pursuant to the date-applicable Florida Medical EDI Implementation Guide (MEIG) and subparagraphs (4)(c)2.-5. of this rule.

(g) When an injured employee does not have a Social Security Number or division-assigned number, the insurer must contact the Division via information provided on the following website: http://www.fldfs.com/WC/organization/odqc.html (under Records Management) to obtain a division-assigned number prior to submitting the medical report to the Division.

(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), modifier code(s) and amount(s) charged, as billed by the health care provider when reporting these data to the Division. 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) 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. Secure and/or 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-subparagraphs (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 to the provider 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.

(k) An insurer, service company/TPA or any entity acting on behalf of the insurer shall pay, adjust, disallow or deny billed charges within 45-calendar days from the date insurer received, pursuant to Section 440.20(2)(b), F.S.

(l) In the medical bill claims-handling process, the receipt of medical bills may be based upon receipt by the insurer or there may be an "entity" acting on behalf of an insurer for purposes of receipt of medical bills. Likewise, the payment of medical bills may be based upon payment by the insurer or there may be an "entity" acting on behalf of an insurer for purposes of payment of medical bills. Therefore, to properly reflect receipt date and payment date of medical bills, the medical bill reporting process must accommodate various receipt and payment options.

1. The receipt and payment option utilized by an insurer and reported to the Division must meet one of the following:

a. Both receipt and payment of medical bills are handled by the insurer. This option may be utilized only when the "date insurer received" is the date the insurer gained 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. This option may not be utilized when a health care provider is required by the insurer to submit medical billings to any "entity" other than the insurer.

b. Both receipt and payment of medical bills are handled by any "entity" acting on behalf of the insurer. This option may be utilized only when the "date insurer received" is the date the "entity" acting on behalf of the insurer gained 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. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

c. Receipt of medical bills is handled by the insurer and payment of medical bills is handled by the "entity" acting on behalf of the insurer. This option may be utilized only when the "date insurer received" is the date the insurer gained 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. This option may not be utilized when a health care provider is required by the insurer to submit medical billings to any "entity" other than the insurer.

d. Receipt of medical bills is handled by any "entity" acting on behalf of the insurer and payment of medical bills is handled by the insurer. This option may be utilized only when the "date insurer received" is the date the "entity" acting on behalf of the insurer gained 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. This option may not be utilized when a health care provider is required by the insurer to submit medical billings directly to the insurer.

2. The insurer must:

a. Document the option(s) selected in subparagraph (5)(l)1. of this rule,

b. Document the specific effective date for each option selected,

c. Document the specific role of each "entity" acting on the insurers behalf in the option selected,

d. Make this written documentation available to the Division for audit purposes pursuant to Section 440.525, F.S.,

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

f. Maintain written documentation 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. An insurer and entity may select multiple options for medical bill claims handling between the insurer and the entity based on business practices or whether medical bills are submitted to the insurer electronically or on paper.

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 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)) When submitting Payment Code "x" 1 to the Division, the insurer is declaring that no "entity" as defined in paragraph (1)(u) 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).) When submitting Payment Code "x" 2 to the Division, the insurer is declaring that the specified "entity" as defined in paragraph (1)(u) of this rule 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).) When submitting Payment Code "x" 3 to the Division, the insurer is declaring that no "entity" as defined in paragraph (1)(u) 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).) When submitting Payment Code "x" 4 to the Division, the insurer is declaring that no "entity" as defined in paragraph (1)(u) 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) An insurer, service company/TPA or any entity acting on behalf of the insurer is not required to report electronically as medical payment data to the Division, those payments made for failed appointments for scheduled independent medical examinations, for federal facilities billing on their usual form or for health care providers in subparagraph (4)(b).13 who bill on their invoice or letterhead.

(o) 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 up through the date for reporting production data with the Medical Data System in the Claim Record Layout-Revision "D" as required in subparagraph (6)(f) of this rule:

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.

3. When reporting production data with the Medical Data System in the Claim Record Layout-Revision "D" as required in subparagraph (6)(f) of this rule, the insurer shall comply with the following instructions pertaining to EOBRs: In completing an Explanation of Bill Review (EOBR) an insurer shall, for each line item billed, select the EOBR code(s) from the list below which identifies(y) the reason(s) for the insurer's reimbursement decision for each line item. The insurer may utilize up to three EOBR codes for each line item billed. When utilizing more than one EOBR, the insurer shall list the EOBR codes that describe the basis for its reimbursement decision in descending order of importance. 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, in descending order of importance.

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 Section 440.13(14)(c), F.S.

90 - Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers' Compensation Health Care Provider Reimbursement Manual.

91 - Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers.

92 - Paid: no modification to the information provided on the medical bill: payment made pursuant to Florida Workers' Compensation Reimbursement Manual for Hospitals.

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 Florida reimbursement manual.

95 - Paid: Reimbursement Dispute Resolution: payment made pursuant to receipt of a Determination or Final Order on a Petition for Resolution of Reimbursement Dispute, pursuant to Section 440.13(7), F.S.

(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 the insurer written documentation required in subparagraphs (5)(j)6. and (5)(l)2. of this rule.

(q) An insurer, service company/TPA or any entity acting on behalf of the insurer to pay, adjust, 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, 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) When an insurer, service company/TPA or any entity acting on behalf of the insurer renders reimbursement as pre-payment for medical services, goods or supplies, reimbursement of employee payment or payment for pharmacy first-fill services, the required data elements, optionally including the appropriate Pre-Payment/Employee Payment/First Fill Indicator as described in the MEIG, shall be submitted to the Division within 45 calendar 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.

(t) When an insurer, service company/TPA or any entity acting on behalf of the insurer renders reimbursement following receipt of a Determination or Final Order in response to a petition to resolve a reimbursement dispute filed pursuant to Section 440.13(7), F.S., the insurer shall:

1. Submit the required data elements to the Division within 45 calendar days of rendering reimbursement; and

2. Submit the data as a replacement submission pursuant to the date-appropriate MEIG; and

3. Submit the cumulative, not the supplemental, payment information at the line-item level utilizing EOBR 95 for each line-item reflecting a payment amount differing from the payment amount reported on the original submission; and

4. Report the "Date Insurer Received" as 22 days after the date the Determination was received by certified mail, in instances where the insurer has waived its rights under Section 120, F.S., or report the "Date Insurer Received" as the date the carrier received the Final Order by certified mail, in instances where the insurer has invoked its rights pursuant to Section 120, F.S., whichever occurs first.

(u) When an insurer, service company/TPA, submitter or any entity acting on behalf of the insurer has reported medical claims data to the Division which was not required, the insurer shall withdraw the previously reported data as described in the MEIG.

(v) When an insurer, service company/TPA, any entity acting on behalf of the insurer renders reimbursement for multiple bills received from a health care provider, the insurer shall report required data elements to the Division for each individual bill, including "Date Insurer Received" and "Date Insurer Paid", submitted by the health care provider and shall not combine multiple bills received from a health care provider into a single medical bill data submission (i.e. a single bill equals a single datum transmission).

(6) Insurer Electronic Medical Report Filing to the Division.

(a) Effective 3/16/05, all required medical reports shall be electronically filed with the Division by all insurers.

(b) Required data elements shall be submitted in compliance with the instructions and formats as set forth in the date-appropriate Florida Medical EDI Implementation Guide (MEIG).

(c) The Division will notify the insurer on the "Medical Claim Processing Report" of the corrections necessary for rejected medical reports to be electronically re-filed with the Division. An insurer shall correct and re-file all rejected medical claim reports to meet the filing requirements of paragraph (5)(e) of this rule.

(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 the catastrophic event 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, 200 East Gaines Street, Tallahassee, Florida 32399-4226. Approval to submit in an alternative reporting method and an alternative filing timeline shall be granted by the Division if a catastrophic event 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", 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 Medical EDI 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 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 "C"), between 12/5/05 and 2/24/06 shall begin testing on 4/2/07 and shall complete the testing process with the new Revision "D" record layouts no later than 5/14/07.

2. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout - Revision "C"), between 2/25/06 and 3/31/06 shall begin testing on 5/15/07 and shall complete the testing process with the new Revision "D" record layouts no later than 6/26/07.

3. Submitters who have been approved for reporting production data with the Medical Data System (Record Layout - Revision "C"), between 4/1/06 and the effective date of this rule shall begin testing on 6/27/07 and shall complete the testing process with the new Revision "D" record layouts no later than 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), 2007.

(g) All submitters shall be in production with the new Revision "D" record layouts on 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) Submitters who do not accurately complete and maintain electronic record-layout programming requirements of this rule shall not submit medical reports electronically until the submitter has been approved for reporting production data with the Medical Data System as necessary to meet the filing requirements of paragraph (5)(e) of this rule.

(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.

(b) Pursuant to Section 440.185(9), F.S., the Department shall impose insurer administrative fines for failure to comply with the submission, filing or reporting requirements of this rule. Insurer administrative fines shall be applied as follows:

1. Calculated on a monthly basis for each separate form category (Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11 and DFS-F5-DWC-90) received and accepted by the Division within a specific calendar month; and

2. Insurers are required to report all medical reports timely pursuant to paragraph (5)(e) of this rule. Insurers that fail to submit a minimum of 95% of all medical reports timely are subject to an administrative fine. Each untimely filed medical report which falls below the 95% requirement is subject to the following penalty schedule:

a. 1 - 30 calendar days late $5.00;

b. 31 - 60 calendar days late $10.00;

c. 61 - 90 calendar days late $25.00;

d. 91 or greater calendar days late $100.00.

3. Each medical report that does not pass the electronic reporting edits shall be rejected by the Division and considered not filed pursuant to paragraph (5)(e) of this rule. If the medical report remains rejected and not corrected, resubmitted and accepted by the Division for greater than 90 days, an administrative fine shall be assessed in the amount of $100.00 for each such medical report. Rejected and not resubmitted medical reports will not be included in the 95% timely reporting requirement.

4. Untimely filed medical reports for a given month will be excluded from the administrative fine set forth in subparagraph (7)(b)3. above as falling within the performance standard between 100% and 95% in the following order:

a. Medical Reports filed 1 - 30 calendar days late; then

b. Medical Reports filed 31 - 60 calendar days late; then

c. Medical Reports filed 61 - 90 calendar days late; then

d. Medical Reports filed 91+ calendar days late.

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, 3-8-07.