Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69L - Division of Workers' Compensation › Chapter 69L-31 - UTILIZATION AND REIMBURSEMENT DISPUTE RULES › Section 69L-31.003 - Petition for Resolution of Reimbursement Dispute Form and Requirements

Current through Reg. 50, No. 138; July 16, 2024
(1) The Petition for Resolution of
				Reimbursement Dispute Form, DFS-F6-DWC-3160-0023, effective 07/2021, is
				incorporated by reference herein. This form may be obtained on the Department's
				website at
https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm
or at
https://www.flrules.org/Gateway/reference.asp?No=Ref-13337
or by contacting the Department at (850)413-1613.
(2) A petition to contest Carrier
				disallowance or adjustment of payment pursuant to Section
				 440.13(7)(a),
				F.S., must be made on the Petition Form. The Department will not accept any
				other form or document in lieu of the Petition Form.
(3) The Petitioner must submit the Petition
				Form to the Department within the timeframe set forth in Section
				 440.13(7)(a),
				F.S., and must include with the Petition Form the documents listed below that
				support the allegations contained in the Petition Form:
(a) A copy of each Notice of Disallowance or
				Adjustment received from the Carrier and, if applicable, proof of the date of
				receipt, as required by subsection
				 69L-31.008(1),
				F.A.C.;
(b) A copy of all medical
				bill(s) or request(s) for reimbursement sent to the Carrier for which payment
				was disallowed or adjusted by the Carrier on each Notice of Disallowance or
				Adjustment;
(c) A copy of all
				documentation submitted to the Carrier in support of the medical service(s),
				bill(s), or request(s) for reimbursement that are subject to the
				dispute;
(d) If the services
				provided in the Notice of Disallowance or Adjustment were alleged by the
				Carrier as being reimbursed pursuant to a contract:
1. Documentation substantiating the contract
				was in effect for the line item(s) in dispute and the provision which governs
				reimbursement for the services if Petitioner is disputing payment was made at
				an amount that is less than the amount prescribed in such a contract;
				or
2. Documentation substantiating
				the contract was in effect and the terms of the contract which evidence its
				inapplicability to the line item(s) in dispute if Petitioner is disputing the
				applicability of the contract to the line item(s) in dispute; or
3. Petitioner shall indicate on question 4 of
				the Petition Form that no contract existed between parties if the Petitioner
				disputes that a contract ever existed; or
4. Documentation substantiating that there
				was no contract in effect for the line item(s) in dispute if Petitioner
				disputes that a contract, which had been in effect at one time, was no longer
				in effect for the line item(s) in dispute;
(e) If the Medical Necessity of the services
				in the Notice of Disallowance or Adjustment are being disputed, supporting
				medical notes and records for the line item(s) in dispute must be provided; a
				Letter of Medical Necessity signed by the Health Care Provider who provided the
				services in the contested line item(s) in the Notice of Disallowance or
				Adjustment describing the Medical Necessity of the services may be provided in
				addition to the supporting medical notes and records;
(f) If the authorization for the services in
				the Notice of Disallowance or Adjustment are being disputed, all of the
				Petitioner's documentation, records, and correspondence related to the
				authorization or request for authorization, if any; and
(g) Any additional documents or records that
				support the allegations contained in the Petition Form.