Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-7 - WORKERS' COMPENSATION MEDICAL REIMBURSEMENT AND UTILIZATION REVIEW › Section 69L-7.740 - Insurer Authorization and Medical Bill Review Responsibilities

Current through Reg. 50, No. 138; July 16, 2024
(1) An insurer is responsible for meeting its
				obligations under this rule regardless of any business arrangements with any
				claim administrator or any entity acting on behalf of an insurer under which
				medical bills are paid, adjusted, disallowed, denied, or otherwise processed or
				submitted to the Division.
(2)
(a) At the time of authorization for medical
				service(s) or upon receipt of notification of emergency care, an insurer shall
				notify each health care provider, in writing, of data elements or supporting
				documentation necessary for reimbursement determinations that are in addition
				to the requirements of this rule and the applicable reimbursement
				manual.
(b) This subpart applies to
				dates of injury occurring on or after October 1, 2003. At the time of
				authorization for medical service(s), or upon receipt of notification of
				emergency care, an insurer shall issue a written or electronic notice to each
				health care provider stating whether the insurer will, when paying
				reimbursement for the medical service(s) for a compensable injury, apportion
				out the percentage of need for the care attributable to a pre-existing
				condition pursuant to Section
				 440.15(5), F.S.
				If the insurer decides to apportion out the percentage of need for the care
				attributable to the pre-existing condition after authorization, the insurer
				shall issue a written or electronic notice to each health care provider stating
				that the insurer will apply such apportionment, pursuant to Section
				 440.15(5),
				F.S., to the reimbursement for the authorized medical service(s). Compliance
				with this subpart is independent of and does not satisfy the notification
				requirement pursuant to Rule
				 69L-3.017, F.A.C.
(c) Medication is treatment. When physicians
				(including oral surgeons), physician assistants, ARNPs, and any other
				recognized practitioners registered to dispense medications pursuant to Section
				 465.0276, F.S., submit a medical
				bill for reimbursement of dispensed medication, the insurer, claim
				administrator, or entity acting on behalf of the insurer may disallow payment
				for dispensed medication if the medication is not authorized prior to
				dispensing, pursuant to Section
				 440.13(3)(a),
				F.S., and is not medically necessary to treat the compensable injury.
				Dispensing such medications may not be denied, absent a contrary contractual
				provision, and reimbursement may not be disallowed or adjusted for the sole
				reason that the injured worker chooses to receive such medications from a
				practitioner registered to dispense medications under Chapter 465, F.S. Any
				response to a request for authorization must be communicated electronically or
				by telephone to the health care provider and must be documented in the claims
				administration system. Failure to timely respond to the written request for
				authorization shall be governed by Section
				 440.13(3)(d),
				F.S.