Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-34 - CARRIER REPORT OF HEALTH CARE PROVIDER VIOLATIONS › Section 69L-34.003 - Elective Referral of Alleged Health Care Provider Violation

Current through Reg. 50, No. 138; July 16, 2024
(1) Any person who elects to submit a report
				of a violation, as defined in this rule chapter, directly to the Division's
				Office of Medical Services, shall use the Health Care Provider Violation
				Referral Form, DFS-F6-DWC-2000
http://www.flrules.org/Gateway/reference.asp?No=Ref-00278
(Effective: August 2011), (hereinafter "Referral Form"), which is hereby
				incorporated by reference. The Referral Form is available via the Division's
				web site at
http://www.myfloridacfo.com/wc/provider/index.html
.
(2) Such person shall submit to the Division
				a separate Referral Form, DFS-F6-DWC-2000
http://www.flrules.org/Gateway/reference.asp?No=Ref-00278
(Effective: August 2011), and all supportive documentation for each alleged
				violation.
(3) Such person shall
				serve a copy of the Referral Form, DFS-F6-DWC-2000
http://www.flrules.org/Gateway/reference.asp?No=Ref-00278
(Effective: August 2011), and all supportive documentation on the Provider
				utilizing a verifiable delivery process, such as United States Postal Service
				certified mail or a similar process offered by a common carrier.
(4) Supportive documentation of a specific
				violation may include, but is not limited to, the following documents or
				records:
(a) All DFS-F5-DWC-25 forms submitted
				by the Provider for the authorization of treatment provided or prescribed for
				the date(s) of service under review and the Carrier's response to each request
				for authorization. Form DFS-F5-DWC-25 (Florida Workers' Compensation Uniform
				Medical Treatment/Status Reporting Form) is incorporated by reference in
				paragraph  69L-7.720(1)(d),
				F.A.C.
(b) Electronic or written
				correspondence between the Carrier and the Provider regarding the medical
				necessity of treatment prescribed or rendered on the date(s) of service under
				review.
(c) All carrier notices of
				disallowance or adjustment of reimbursement within the meaning of Section
				 440.13(7),
				F.S., for the date(s) of service and treatment under review (e.g., Explanations
				of Bill Reviews or EOBRs).
(d) A
				copy of each medical bill for the date(s) of service under review, which lists
				the line item service disallowed or adjusted on the basis of overutilization,
				or improper billing, or a billing error.
(e) Peer review report(s) substantiating a
				standard of care violation, including overutilization of services, for the
				date(s) of service under review with specific reference to the practice
				guidelines upon which the peer review finding is based.
(f) Electronic or written request(s) sent to
				the Provider for a refund of reimbursement for line item service(s) that
				constituted overutilization or an improper billing or a billing
				error.
(g) Electronic or written
				request(s) sent to the Provider for medical records and information or for the
				submission of Form DFS-F5-DWC-25.
(h) Electronic or written correspondence
				notifying the Provider of the Carrier's responsibility for the payment of
				medical services rendered for authorized treatment pursuant to the applicable
				reimbursement manual and the Provider's inability to balance bill the injured
				worker.
(i) Copies of collection
				letters sent to the injured worker from the Provider or a collection agent
				acting on behalf of the Provider, seeking payment for covered medical services
				authorized by the Carrier.
(j) A
				copy of a Determination, issued by the Division, finding that the Provider
				improperly billed and is not entitled to additional reimbursement or the amount
				of reimbursement due is less than the amount the Carrier reimbursed for the
				billed service(s).