Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-24 - INSURERS' STANDARDS AND PRACTICES › Section 69L-24.005 - Maintaining and Providig Records

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Pursuant to Section  440.525(1),
				F.S., the Department may examine and investigate regulated entities as often as
				is warranted to ensure that they are fulfilling their obligations under Chapter
				440, F.S. The Department shall have the power to conduct onsite inspections of
				claims records and documentation of an insurer, third-party administrator,
				servicing agent, or other claims-handling entity, and conduct interviews, both
				sworn and un-sworn, of claims-handling personnel. Insurers, third-party
				administrators, servicing agents, and other claims-handling entities shall make
				all claims records, documentation, communication, and correspondence available
				to Department personnel during regular business hours, pursuant to Section
				 440.525(3),
				F.S. All regulated entities shall provide to the Department all information and
				documentation that is requested for the purposes of monitoring, examining, or
				investigating the regulated entity's operations and processes. Such information
				and documentation, including specific data, shall be made available to the
				Department within 14 calendar days of receipt of any request by the Department
				unless the Department allows an extension of time.
(2) For examinations or investigations, if
				the regulated entity maintains hard-copy files, the hard-copy files shall be
				made available to the Department on or before the date requested by the
				Department. If the regulated entity maintains electronic files and an
				examination or investigation is conducted at the regulated entity's offices, a
				sufficient number of functioning computers shall be made available to the
				Department for access to the electronic claims documents and information.
				Requests for information may include, but are not limited to:
(a) The date of notification or knowledge of
				the injury. "Notification" and "knowledge" are defined in subsections
				 69L-3.002(23) 
				and  69L-56.002(40),
				F.A.C.;
(b) The date of initial
				disability, the eighth day of disability and knowledge of the eighth day of
				disability;
(c) The date each
				indemnity payment was mailed to the injured worker, the amount of the payment,
				and the period of time that was covered in the payment;
(d) The date that Forms DFS-F5-DWC-9 (Health
				Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement of Charges for Drugs
				and Medical Supplies Form and Instructions), DFS-F5-DWC-11 (American Dental
				Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital Billing Form
				(UB-04), or their electronic equivalents, as incorporated in paragraphs
				 69L-7.720(1)(a), (b), (c), and
				(e), F.A.C., were received from the health
				care provider pursuant to paragraph
				 69L-7.710(1)(o),
				F.A.C.;
(e) The date that Forms
				DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement
				of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11
				(American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital
				Billing Form (UB-04), or their electronic equivalents, were paid, disallowed,
				or denied;
(f) The date that Forms
				DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement
				of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11
				(American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital
				Billing Form (UB-04), or their electronic equivalents, were mailed or
				transmitted to the Department;
(g)
				The date that Form DFS-F2-DWC-60 (Important Workers' Compensation Information
				for Florida's Workers' brochure) or DFS-F2-DWC-61 (Informacion Importante De
				Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La
				Florida) was mailed to the injured worker;
(h) The date that Form DFS-F2-DWC-65
				(Important Workers' Compensation Information for Florida's Employers), or Forms
				DFS-F2-DWC-66 (Informacion Importante Del Seguro De Indemnizacion Por
				Accidentes De Trabajo Para Los Empleadores De La Florida), as incorporated in
				Rule  69L-3.025, F.A.C., was mailed to
				the employer;
(i) The date that the
				Employee Notification Letter, as incorporated in subsection
				 69L-26.004(6),
				F.A.C., was mailed to the injured worker;
(j) The date that any written request for
				medical authorization was received and the date that the medical authorization
				was granted in response to the written request;
(k) Electronic Data Interchange (EDI)
				transactions and requirements pursuant to Rule  69L-56.001 through
				 69L-56.500, F.A.C.;
(l) The date that the 120-day notice required
				under Section  440.20(4), F.S.
				was mailed;
(m) All diary notes,
				claim notes, and correspondence available for review during an examination,
				audit or investigation.