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-7.710 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
(1) As used in this chapter:
(a) "Accurately Complete" or "Accurately
				Completed" means the form submitted contains the information necessary to meet
				the requirements of Chapter 440, F.S., and this rule.
(b) "Adjust" or "Adjusted" means payment is
				made with modification to the information provided on the bill.
(c) "Ambulatory Surgical Center" or "ASC" is
				defined in Section  395.002(3),
				F.S.
(d) "Average Wholesale Price"
				or "AWP" is as defined in Section
				 440.13(12)(c),
				F.S., for medications dispensed on or after July 1, 2013.
(e) "Billing" means the process by which a
				health care provider submits a medical claim form or medical bill to an
				insurer, claim administrator or any entity acting on behalf of the insurer, to
				receive reimbursement for medical services, goods or supplies provided to an
				injured employee.
(f) "Catastrophic
				Event" means the occurrence of an event outside the control of a claim
				administrator or any entity acting on behalf of the insurer, such as an
				electronic data transmission failure due to a natural disaster or an act of
				terrorism (including but not limited to cyber terrorism), in which recovery
				time will prevent a claim administrator or any entity acting on behalf of the
				insurer from meeting the filing and reporting requirements of Chapter 440,
				F.S., and rule Chapter 69L-7, F.A.C. Programming errors, system malfunctions or
				electronic data interchange transmission failures that are not a direct result
				of a catastrophic event are not considered to be a catastrophic event as
				defined herein. See subsection
				 69L-7.750(4),
				F.A.C., for requirements to request approval of an alternative method and
				timeline for medical report filing with the Division due to a catastrophic
				event.
(g) "Charges" means the
				dollar amount billed.
(h) "Charge
				Master" means for hospitals a comprehensive listing of all the goods and
				services for which the facility maintains a separate charge, with the
				facility's charge for each of the goods and services, regardless of payer type
				and means; for ASCs a listing of the gross charge for each CPT procedure for
				which an ASC maintains a separate charge, with the ASC's charge for each CPT
				procedure, regardless of payer type.
(i) "Claim Administrator" means any insurer,
				qualified servicing entity, third party administrator, claims-handling entity,
				self-serviced self-insured employer or fund, guarantee fund, or managing
				general agent responsible for adjusting workers' compensation claims.
(j) "Claim Administrator Code Number" means
				the number the Division assigns to an Insurer, qualified servicing entity,
				third party administrator, claims-handling entity, self-serviced self-insured
				employer or fund, guarantee fund, or managing general agent responsible for
				adjusting workers' compensation claims.
(k) "Claim Administrator File Number" means
				the number assigned to the claim file by the claim administrator for purposes
				of internal tracking.
(l) "Current
				Dental Terminology" (CDT) means the American Dental Association's reference
				document containing descriptive terms to identify codes for billing and
				reporting dental procedures, as incorporated by reference in rule Chapter
				69L-8, F.A.C.
(m) "Current
				Procedural Terminology" (CPT®) means the
				American Medical Association's reference document (HCPCS Level I) containing
				descriptive terms to identify codes for billing and reporting medical
				procedures and services, as incorporated by reference in rule Chapter 69L-8,
				F.A.C.
(n) "Date Insurer Paid Bill"
				and "Date Insurer Paid, Adjusted, Disallowed or Denied" means the date the
				claim administrator or any entity acting on behalf of the insurer mails,
				transfers or electronically transmits payment to the health care provider or
				the health care provider representative. If payment is disallowed or denied,
				"Date Insurer Paid Bill" and "Date Insurer Paid, Adjusted, Disallowed or
				Denied" means the date the claim administrator or any entity acting on behalf
				of the insurer mails, transfers or electronically transmits the appropriate
				notice of disallowance or denial to the health care provider or the health care
				provider representative. See subsection
				 69L-7.750(8),
				F.A.C., for the requirement to accurately report the "Date Insurer Paid
				Bill."
(o) "Date Insurer Received
				Bill" means the date that a Form DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer
				pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic
				form equivalent is in the possession of the claim administrator or any entity
				acting on behalf of the insurer. See subsection
				 69L-7.750(8),
				F.A.C., for the requirement to accurately report the "Date Insurer Received
				Bill." If a medical bill meets any of the criteria in paragraph
				 69L-7.740(11)(g),
				F.A.C., and possession of the form is relinquished by the claim administrator
				or any entity acting on behalf of the insurer by returning the medical bill to
				the provider with a written explanation for the insurer's reason for return,
				then "Date Insurer Received Bill" shall not apply to the medical bill as
				submitted.
(p) "Days" means
				calendar days unless otherwise noted.
(q) "Deny" or "Denied" means payment is not
				made because the service rendered is for treatment of a non-compensable injury
				or illness.
(r) "Department" means
				Department of Financial Services (DFS) as defined in Section
				 440.02(12),
				F.S.
(s) "Disallow" or "Disallowed"
				means payment for a compensable injury or illness is not made because the
				service rendered has not been substantiated for reasons of medical necessity,
				insufficient documentation, lack of authorization or billing error.
(t) "Division" means the Division of Workers'
				Compensation (DWC) as defined in Section
				 440.02(14),
				F.S.
(u) "Electronic Filing" means
				the computer exchange of medical data from a sender to the Division in the
				standardized format defined in the Florida Medical EDI Implementation Guide
				(MEIG).
(v) "Electronic Form
				Equivalent" means the record, provided in the Florida Medical EDI
				Implementation Guide MEIG to be used when a sender electronically transmits
				required data to the Division. Electronic form equivalents do not include
				transmission by facsimile, data file(s) attached to electronic mail, or
				computer-generated paper-forms.
(w)
				"Electronically Filed with the Division" means the date an electronic filing
				has been received by the Division and has successfully passed structural and
				data-quality edits.
(x) "Entity"
				means any party involved in the processing, adjudication or payment of medical
				bills on behalf of the insurer.
(y)
				"Explanation of Bill Review" (EOBR) means the document used to provide notice
				of payment or notice of adjustment, disallowance or denial by a claim
				administrator or any entity acting on behalf of an insurer to a health care
				provider containing code(s) and code descriptor(s), in conformance with
				subsection  69L-7.740(13),
				F.A.C.
(z) "Explanation of Bill
				Review Code" (EOBR Code) means a code listed in paragraph
				 69L-7.740(13)(b),
				F.A.C., that describes the basis for the reimbursement decision of a claim
				administrator or any entity acting on behalf of the insurer.
(aa) "Florida Medical EDI Implementation
				Guide (MEIG)" is the Florida Division of Workers' Compensation's reference
				document containing the specific electronic formats, data elements, and
				requirements for insurer reporting of medical data to the Division, as
				incorporated by reference in rule Chapter 69L-8, F.A.C.
(bb) "Healthcare Common Procedure Coding
				System National Level II Codes (HCPCS)" means the Centers for Medicare and
				Medicaid Services' (CMS) reference document listing descriptive codes for
				billing and reporting professional services, procedures, and supplies provided
				by health care providers, as incorporated by reference in rule Chapter 69L-8,
				F.A.C.
(cc) "Health Care Provider"
				is defined in Section
				 440.13(1)(g),
				F.S.
(dd) "Home Health Agency"
				(HHA) is defined in Section
				 400.462(12),
				F.S.
(ee) "Home Medical Equipment
				Provider," sometimes referred to as "durable medical equipment (DME) provider,"
				is defined in Section
				 400.925(7),
				F.S.
(ff) "Hospital" is defined in
				Section  395.002(12),
				F.S.
(gg) "ICD-9-CM International
				Classification of Diseases" (ICD-9) is the U.S. Department of Health and Human
				Services' reference document listing the official diagnosis and inpatient
				procedure code sets, as incorporated by reference in rule Chapter 69L-8,
				F.A.C.
(hh) "ICD-10 International
				Classification of Diseases" (ICD-10) is the 10th Edition of the International
				Classification of Diseases set of diagnosis and inpatient procedure codes, as
				incorporated by reference in rule Chapter 69L-8, F.A.C.
(ii) "Implants" means the Surgical
				Implant(s), the Associated Disposable Instrumentation required for use with the
				Surgical Implant(s), and shipping and handling, when listed on the implant
				invoice or certified on the DFS-F5-DWC-90 claim form.
(jj) "Insurer" is defined in Section
				 440.02(38),
				F.S.
(kk) "Insurer Code Number"
				means the number the Division assigns to each individual insurer, self-insured
				employer, self-insured fund, or guaranty fund financially responsible for the
				claim.
(ll) "Itemized Statement"
				means a detailed listing of goods, services and supplies provided to an injured
				employee, including the quantity and charges for each good, service or
				supply.
(mm) "Medical Bill" means
				the document or electronic form equivalent submitted by a health care provider
				to an Insurer, Service Company/Third Party Administrator or any entity acting
				on behalf of the Insurer for reimbursement for services or supplies (e.g.,
				DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider's
				usual invoice or business letterhead) as appropriate pursuant to subsection
				 69L-7.730(2),
				F.A.C.
(nn) "Medically Necessary"
				or "Medical Necessity" is defined in Section
				 440.13(1)(k),
				F.S.
(oo) "NDC Number" means the
				eleven-digit National Drug Code (NDC) number, assigned under Section 510 of the
				Federal Food, Drug, and Cosmetic Act, which identifies the drug product
				labeler/vendor, product, and trade package size. As used in this rule chapter,
				when referring to dispensed drugs, "Original Manufacturer's NDC Number" shall
				mean the NDC Number assigned by the original manufacturer of the underlying
				dispensed drug; and, "Repackaged NDC Number" shall mean the NDC Number assigned
				by the repackager/relabeler of the underlying dispensed drug.
(pp) "Nursing Home Facility" is defined in
				Section  400.021(12),
				F.S.
(qq) "Pay" or "Paid" means
				payment is made applying the applicable reimbursement formula to the medical
				bill as submitted.
(rr) "Physician"
				is defined in Section
				 440.13(1)(p),
				F.S.
(ss) "Primary Physician" means
				the treating physician responsible for the oversight of medical care, treatment
				and attendance rendered to an injured employee, to include recommendation for
				appropriate consultations or referrals.
(tt) "Recognized Practitioner" means a
				non-physician health care provider licensed by the Department of Health who
				works under the protocol of a physician or who, upon referral from a physician,
				can render direct billable services that are within the scope of the recognized
				practitioner's license, independent of the supervision of a
				Physician.
(uu) "Report" means any
				form related to medical services rendered, in relation to a workers'
				compensation injury that is required to be filed with the Division under rule
				Chapter 69L-7, F.A.C.
(vv) "Service
				Company/Third Party Administrator (TPA)" means an entity that has contracted
				with an insurer for the purpose of providing services necessary to adjust
				workers' compensation claims on the Insurer's behalf.
(ww) "Sender" means an Insurer, Service
				Company/TPA, entity or any other party acting on behalf of an Insurer, Service
				Company/TPA or any entity to fulfill any Insurer responsibility to
				electronically transmit required medical data to the Division.
(xx) "UB-04 Manual" means the National
				Uniform Billing Committee Official UB-04 Data Specifications Manual, which is
				the reference document providing billing and reporting completion instructions
				for the Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev.11/03/2006), as
				incorporated by reference in Rule
				 69L-8.074,
				F.A.C.