Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-56 - ELECTRONIC DATA INTERCHANGE (EDI) REQUIREMENTS FOR PROOF OF COVERAGE AND CLAIMS (NON-MEDICAL) › Section 69L-56.4012 - Notice of Denial

Current through Reg. 50, No. 138; July 16, 2024
(1) If the claim
				administrator denies entitlement to any benefit, or subsequently rescinds that
				denial, it shall send a copy of Form DFS-F2-DWC-12, as adopted in Rule
				 69L-3.025, F.A.C., to the
				employee, employer and any additional party requesting payment or
				authorization. The Form DFS-F2-DWC-12 shall be mailed within 14 days of the
				date the claim administrator decided to deny or rescind the denial of
				benefits.
(2) If the claim
				administrator initially denies the compensability of or coverage for a case, it
				shall send Form DFS-F2-DWC-12 to the Division within 14 days after the claim
				administrator receives notification of the injury, illness or death. The claim
				administrator shall also mark the "Denied Case" box on Form DFS-F2-DWC-1
				pursuant to sub-subparagraph
				 69L-56.4011(1)(d) 
				5.a., F.A.C.
(3) If the claim
				administrator initially denies only the indemnity benefits of a claim, it shall
				send Form DFS-F2-DWC-12 to the Division within 14 days after the claim
				administrator's notification of the injury, illness or death. The claim
				administrator shall also mark the "Indemnity Only Denied Case" box on Form
				DFS-F2-DWC-1, as adopted in Rule
				 69L-3.025, F.A.C., pursuant to
				sub-subparagraph  69L-56.4011(1)(d) 
				5.b., F.A.C.
(4) When the claim
				administrator denies any subsequent indemnity benefit on a lost time case, it
				shall send Form DFS-F2-DWC-12. The Form DFS-F2-DWC-12 shall be sent to the
				Division within 14 days of the claim administrator's knowledge of the requested
				benefit being denied.
(5) If a
				Petition for Benefits is the claim administrator's first notification of an
				injury and the claim administrator denies the case in its entirety, it shall
				send Forms DFS-F2-DWC-12 and DFS-F2-DWC-1 to the Division within 14 days of the
				claim administrator's receipt of the Petition for Benefits.
(6) When the claim administrator has
				previously denied any indemnity benefits for a lost time case and has sent Form
				DFS-F2-DWC-12 to the Division, and then commences the payment of indemnity
				benefits, the claim administrator shall send Form DFS-F2-DWC-12 with the denial
				rescinded section completed. The "Date Denial Rescinded" is the date the claim
				administrator decided to rescind the denial. The Form DFS-F2-DWC-12 shall be
				sent to the Division within 14 days of the date that the denial was
				rescinded.
(7) When an employee
				requests wage loss benefits for dates of accident August 1, 1979 through
				December 31, 1993, by sending Form DFS-F2-DWC-3, as adopted in Rule
				 69L-3.025, F.A.C., to the claim
				administrator, and the wage loss calculation yields an amount of benefits
				payable, but the claim administrator denies or disputes the employee's
				eligibility for those benefits, the claim administrator shall, within 14 days
				of receipt of the Form DFS-F2-DWC-3:
(a) Send
				to the Division the following:
1. Form
				DFS-F2-DWC-3, completed by the employee and the claim administrator;
2. Form DFS-F2-DWC-12; and,
3. A copy of any information or document
				relating to the employee's job search.