Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-10 - CLAIM FOR REIMBURSEMENT AGAINST THE SPECIAL DISABILITY TRUST FUND › Section 69L-10.016 - Documenting Expenditures for Purposes of Obtaining Reimbursement

Current through Reg. 50, No. 138; July 16, 2024
In order to obtain reimbursement after an offer of
				  reimbursement has been extended by the Fund, an employer/carrier shall file
				  with the Fund a Form DFS-F1-SDF-2, as adopted in rule
				   69L-10.019, F.A.C., with
				  supporting schedules and documentation of expenditures as set forth
				  below.
(1) Expenditures for Medical
				Benefits. Expenditures for medical benefits must be documented by the
				submission of applicable Division forms, as adopted in rule
				 69L-3.025, F.A.C., showing
				compliance with the fee schedules adopted in rule
				 69L-7.020, F.A.C., and
				applicable utilization review procedures such as medical bills marked "paid" or
				an EOB that was completed contemporaneously with the processing of the medical
				payments together with corroborating documentation of amount paid (e.g.,
				computer printouts, ledger sheets, or copies of checks). The EOB shall be in
				the format prescribed by the Fund in DFS Form DFS-F1-SDF-6, REV. 3-09, which
				form is hereby adopted by reference. DFS Form DFS-F1-SDF-6 may be obtained from
				the SDTF at the address set out in rule
				 69L-10.019, F.A.C. If the
				carrier is unable to provide the data on the forms adopted by this section they
				may submit their own version of an EOB provided that it contains all of the
				elements of the DFS-F1-SDF-6. The SDTF shall request additional information
				documenting expenditures by health care providers if necessary to prove that
				the benefits requested for reimbursement are related to the injury and are
				required to be provided under section
				 440.49, F.S. Computer printouts
				or ledger sheets are not acceptable forms of documenting expenditures for
				medical benefits unless accompanied by medical bills marked paid or an
				DFS-F1-SDF-6 or its equivalent.
(2)
				Expenditures for Compensation Voluntarily Paid.
(a) When temporary or permanent disability
				compensation, permanent impairment benefits, or death benefits have been
				voluntarily paid, such benefits may be documented by Progress/Final Report, DFS
				DWC-13 forms, as adopted in rule
				 69L-3.025, F.A.C., which were
				prepared contemporaneously with payment, or by copies of checks. If the DWC-13
				forms were not prepared contemporaneously with the payment of compensation,
				computer printouts or ledger sheets may be used to corroborate the payment.
				However, in regard to each of these classes of benefits, if the total payment
				listed on the DWC-13 form, printout, or ledger for a particular class is
				greater than the rate of compensation multiplied by the number of calendar
				weeks in the period, copies of checks must be supplied to document
				expenditures.
(b) When wage-loss
				benefits have been voluntarily paid, such benefits shall be documented only by
				copies of checks or by copies of fully completed Request for Wage
				Loss/Temporary Partial Benefits, DWC-3 forms, as adopted in rule
				 69L-3.025,
				F.A.C.