Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-3 - WORKERS' COMPENSATION CLAIMS › Section 69L-3.003 - Procedures for Filing Documents

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Instructions on or pertaining to forms promulgated under this chapter, are also
				rules under this chapter and forms shall be completed in accordance with such
				instructions. When forms are reproduced, they shall be reproduced in their
				entirety, including instructions. The claim administrator shall ensure that all
				documents filed with the Division pursuant to this rule chapter are complete
				and legible. These documents shall be filed with the Florida Department of
				Financial Services, Division of Workers' Compensation, 200 East Gaines Street,
				Tallahassee, Florida 32399-4226, except as otherwise indicated. The Division
				shall return to the claim administrator any document on which the appropriate
				information required in subsection (3) of this rule and paragraph
				 69L-56.4011(1)(d),
				F.A.C., does not appear, and will notify the claim administrator of its error
				or omission. If a document is not complete and legible, the Division will
				return it to the claim administrator's address as provided on the form for
				correction or completion. The claim administrator shall make the correction,
				include a revised "Sent to Division Date" and resubmit the document to the
				Division. The document will be considered completed and in compliance with this
				section when the corrected document is resent and accepted by the
				Division.
(2) Claim administrators
				shall respond to any written request for information by the Division no later
				than 14 days after receiving the request, except as otherwise provided in rule
				chapter 69L-3, F.A.C.
(3) The claim
				administrator, where required, shall include on every document it submits to
				the Division the following information:
(a)
				The employee's name.
(b) The
				employee's social security number as assigned by the Social Security
				Administration. If the employee does not have a social security number, the
				claim administrator shall email the Division at
				DWCAssignedNumber@myfloridacfo.com to obtain a Division assigned number until
				the social security number is obtained. Upon receipt of the employee's social
				security number, the claim administrator shall file Form DFS-F2-DWC-4, as
				adopted in rule  69L-3.025, F.A.C., with the
				Division in accordance with rule
				 69L-56.404, F.A.C.
(c) The month, day, and year of the
				employee's accident or illness, in the following order: mm-dd-yy or
				mm-dd-ccyy.
(d) The "Insurer Code
				#". A claim administrator adjusting claims for one or more insurers shall
				report the correct "Insurer Code #" for each specific claim.
(e) The "Service Co/TPA Code #". If a
				third-party administrator, servicing agent, or other claim administrator is
				servicing a claim for an insurer, self-insured employer or self-insurance fund,
				it shall include both the "Insurer Code #" and the "Service Co/TPA Code #" on
				any form
.
(f) The
				"Claims-handling Entity File #". A claim administrator shall report its
				internal identification number assigned to a file on forms as required under
				this chapter.
(g) The name, address
				and telephone number of the claim administrator. When a "Service Co/TPA" is
				adjusting claims for an insurer, the name, address and telephone number of the
				"Service Co/TPA" in addition to the name of the insurer shall be provided. The
				telephone number provided shall enable a caller to readily contact the office
				handling the claim.
(h) The "Sent
				to Division Date".