Florida Workers’ Compensation Medical Services Billing, Filing, and Reporting Rule Development Underway
May 24, 2013
The Florida Department of Financial Services, Division of Workers’ Compensation advised today, May 24, 2013, that Rule development has commenced on the Florida Workers’ Compensation Medical Services Billing, Filing, and Reporting Rule (Rule 69L-7.602, Florida Administrative Code).
To view the complete notice, click here.
A Rule Development Workshop, if requested in writing, will be held on Thursday, June 6, 2013 at 10:00 a.m., (EDT) in Room 102 of the Hartman Building in Tallahassee to amend the current regulation so that insurers are relieved of the obligation of issuing an Explanation of Bill Review (“EOBR”) when providing reimbursement to pharmacies or pharmacists licensed under Chapter 465, F.S. for contracted pharmaceutical services.
If, prior to the date of service, the carrier or its representative has a contract with a pharmacy or pharmacist or their representative that governs the reimbursement and specifies the amount to be reimbursed (by value or formula), the carrier would be relieved of the obligation of issuing an EOBR to that pharmacy or pharmacist.
The preliminary text of the proposed changes is:
69L-7.602 Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule
(1) through (4) No Change.
(5) Insurer Responsibilities.
(a) through (p) No Change.
(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 detailing the adjudication of the submitted bill by line item, utilizing only the EOBR codes and code descriptors per line item, as set forth in paragraph (o) of this section, and shall include the insurer name, Division issued insurer number and corresponding insurer mailing address. However, an insurer may choose to append an internal reason code to the EOBR it submits to the health care provider, when utilizing an EOBR code set forth in paragraph (o) that includes a code descriptor requiring the insurer to provide additional specification. 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. The requirements of this paragraph do not apply to adjudication of a bill for pharmaceutical services provided by a pharmacist or pharmacy licensed under Chapter 465, F.S., and billed on a Form DFS-F5-DWC-10 or its electronic equivalent, where, prior to the services being rendered, a binding contract exists between the insurer, service company/TPA or any entity acting on behalf of the insurer, and the pharmacist or pharmacy or its representative that governs and specifies the amount to be paid by or on behalf of the insurer for the services.
(r) through (v) No Change.
(6) No Change.
Rulemaking Authority 440.13(4), 440.15(3)(b), (d), (f), 440.185(5), 440.20.(6)(b), 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), (f), (5), 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, 1-12-10, 10-23-12, _________.
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