(4) Health Care Provider Responsibilities.
(a) Bill Submission/Filing and Reporting Requirements.
1. All health care providers are responsible for meeting their
obligations, under this rule, regardless of any business arrangement
with any entity under which claims are prepared, processed or
submitted to the insurer.
2. Each health care provider is responsible for submitting any
additional form completion information and supporting documentation
requested, in writing, by the insurer at the time of authorization
or at the time a reimbursement request is received.
3. Each health care provider shall resubmit a medical claim form or
medical bill with insurer requested documentation when the EOBR
provides an explanation for disallowance based on the lack of
documentation submitted with the medical bill.
4. Insurers and health care providers shall utilize only the Form
DFS-F5-DWC-25 for physician reporting of the injured employee’s
medical treatment/status. Any other reporting forms may not be used
in lieu of or supplemental to the Form DFS-F5-DWC-25. Provider
failure to accurately complete and submit the DFS-F5-DWC-25, in
accordance with the Form DFS-F5-DWC-25 Completion/Submission
Instructions adopted in this rule, may result in the Agency imposing
sanctions or penalties pursuant to subsection 440.13(8), F.S. or
subsection 440.13(11), F.S.
a. The Form DFS-F5-DWC-25 does not replace physician notes, medical
records or Division-required medical reports.
b. All information submitted on physician notes, medical records or
Division-required medical reports must be consistent with
information documented on the Form DFS-F5-DWC-25.
5. All medical claim form(s) or medical bill(s) related to services
rendered for a compensable injury shall be submitted by a health
care provider to the insurer, service company/TPA or any entity
acting on behalf of the insurer, as a requirement for billing.
6. Medical claim form(s) or medical bill(s) may be electronically
filed or submitted via facsimile by a health care provider to the
insurer, service company/TPA or any entity acting on behalf of the
insurer, provided the insurer agrees.
7. When requested by the insurer, service company/TPA or any entity
acting on behalf of the insurer, a health care provider shall send
documentation that supports the medical necessity of the specific
services rendered and any other required documentation pursuant to
paragraph (4)(b) of this rule and the applicable reimbursement
manual.
8. Each health care provider is responsible for correcting and
resubmitting any billing forms returned by an insurer, service
company/TPA or any entity acting on behalf of the insurer pursuant
to paragraph (5)(j) of this rule.
9. Each hospital and ambulatory surgical center shall maintain its
charge master and shall produce relevant portions when requested for
the purpose of verifying its usual charges pursuant to Section
440.13(12)(d), F.S.
(b) Special Billing Requirements.
1. When anesthesia services are billed on a Form DFS-F5-DWC-9,
completion of the form must include the CPT® code and the “P” code
(physical status modifier), which correspond with the procedure
performed, in Field 24D. Anesthesia health care providers shall
enter the date of service and the 5-digit qualifying circumstance
code, which correspond with the procedure performed, in Field 24D on
the next line, if applicable.
2. When an Advanced Registered Nurse Practitioner (ARNP) provides
services as a Certified Registered Nurse Anesthetist, the ARNP shall
bill on a Form DFS-F5-DWC-9 for the services rendered and enter
his/her Florida Department of Health ARNP license number in Field
33b, regardless of the employment arrangement under which the
services were rendered, or the party submitting the bill.
3. Regardless of the employment arrangement under which the services
are rendered or the party submitting the bill, the following health
care providers, who render direct billable services for which
reimbursement is sought from an insurer, service company/TPA or any
entity acting on behalf of the insurer, service company/TPA, shall
bill on a Form DFS-F5-DWC-9 and enter his/her Florida Department of
Health license number in Field 33b on the Form DFS-F5-DWC-9:
a. Any licensed physician; or
b. Any non-physician health care provider, including a physician
assistant or an ARNP (not providing an anesthesia-related service);
or
c. Any licensed non-physician health care provider who is seeking
reimbursement under his or her license number issued by the Florida
Department of Health.
4. For hospital billing, the following special requirements apply:
a. Inpatient billing – Hospitals shall, in addition to filing a Form
DFS-F5-DWC-90:
I. Attach an itemized statement with charges based on the facility’s
Charge Master; and
II. Submit all applicable documentation or certification required
pursuant to Rule 69L-7.501, F.A.C.; and
III. Bill professional services provided by a physician, physician
assistant, advanced registered nurse practitioner, or registered
nurse first assistant on the Form DFS-F5-DWC-9, regardless of
employment arrangement;
IV. When entering the CPT®, HCPCS or unique workers’ compensation
codes in Form Locator 44 on the Form DFS-F5-DWC-90, the hospital
shall utilize CPT®, HCPCS or unique workers’ compensation codes
provided in the Florida Workers’ Compensation Health Care Provider
Reimbursement Manual adopted in Rule 69L-7.501, F.A.C.
b. Outpatient billing – Hospitals shall in addition to filing a Form
DFS-F5-DWC-90:
I. Enter the CPT®, HCPCS or unique workers’ compensation code
(provided in the Florida Workers’ Compensation Health Care Provider
Reimbursement Manual as incorporated for reference in Rule
69L-7.501, F.A.C.) in Form Locator 44 on the Form DFS-F5-DWC-90, to
bill outpatient radiology, clinical laboratory and physical,
occupational or speech therapy charges; and
II. Make written entry “scheduled” or “non-scheduled” in Form
Locator 84 of Form revision 1992 and in Form Locator 80 of Form
revision 2006 – ‘Remarks’ on the DFS-F5-DWC-90, when billing
outpatient surgery or outpatient surgical services; and
III. Make written entry “implant(s)” followed by the reimbursement
calculation made pursuant to Rule 69L-7.501, F.A.C., in Form Locator
84 of Form revision 1992 and in Form Locator 80 of Form revision
2006 – ‘Remarks’ on the DFS-F5-DWC-90, directly after entry of
“scheduled” or “non-scheduled”, when present;
IV. Attach an itemized statement with charges based on the
facility’s Charge Master if there is no line item detail shown on
the Form DFS-F5-DWC-90; and
V. Submit all applicable documentation or certification required
pursuant to Rule 69L-7.501, F.A.C.;
VI. Bill professional services provided by a physician, physician
assistant, advanced registered nurse practitioner, or registered
nurse first assistant on the Form DFS-F5-DWC-9, regardless of
employment arrangement;
5. A certified, licensed physician assistant, anesthesia assistant
and registered nurse first assistant who provides services as a
surgical assistant, in lieu of a second physician, shall bill on a
Form DFS-F5-DWC-9 entering the CPT® code(s) plus modifier(s), which
represent the service(s) rendered, in Field 24D, and must enter
his/her Florida Department of Health license number in Field 33b.
6. Ambulatory Surgical Centers (ASCs) shall bill on a Form
DFS-F5-DWC-9 using the American Medical Association’s CPT® procedure
codes, or using the unique workers’ compensation procedure code
99070 and billing charges based on the ASC’s Charge Master except
when billing for procedure code 99070. ASC medical bills shall be
accompanied by all applicable documentation required pursuant to
Rule 69L-7.100, F.A.C.
7. Federal Facilities shall bill on their usual form.
8. Out-of-State health care providers shall bill on the applicable
medical bill form pursuant to paragraph (4)(c) of this rule.
9. Dental Services.
a. Dentists shall bill for services on a Form DFS-F5-DWC-11.
b. Oral surgeons shall bill for oral and maxillofacial surgical
services on a Form DFS-F5-DWC-9. Non-surgical dental services shall
be billed on a Form DFS-F5-DWC-11.
10. Pharmaceutical(s), Durable Medical Equipment and Medical
Supplies.
a. When dispensing commercially available medicinal drugs commonly
known as legend or prescription drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format, in Field 9, with each
segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9 and shall enter the NDC number, in the universal 5-4-2
format, in Field 24D, with each segment separated by a dash (-).
Optionally, the unique workers’ compensation code 96370 may be
entered in addition to the NDC number in Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
b. When dispensing medicinal drugs which are compounded and the
prescribed formulation is not commercially available:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
unique workers’ compensation code 96371 in Field 9.
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9 and shall enter the unique workers’ compensation code
96371 in form Field 24D.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
c. When dispensing over-the-counter drug products:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format in form Field 9, with each
segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9, shall enter the NDC number in the universal 5-4-2
format, in Field 24D, with each segment separated by a dash (-). The
requirement to enter the NDC number in Field 24D supersedes the
instruction to enter 99070 in the Florida Workers’ Compensation
Health Care Provider Reimbursement Manual.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
d. When administering or dispensing injectable drugs:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
NDC number, in the universal 5-4-2 format, in form Field 9, with
each segment separated by a dash (-).
II. Physicians, physician assistants or ARNPs shall bill on a Form
DFS-F5-DWC-9 and enter the appropriate HCPCS “J” code in form Field
24D. When an appropriate HCPCS “J” code is not available for the
injectable drug, enter the NDC number, in the universal 5-4-2 format
in form Field 24D with each segment separated by a dash (-).
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the
appropriate revenue codes.
e. When dispensing durable medical equipment (DME):
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
applicable HCPCS code in Field 21 on form revision 2/14/06 and in
Field 21 on form revision 1/1/07.
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and
attach documentation indicating the actual cost of the supply,
including applicable manufacturer’s shipping and handling.
III. Hospitals shall bill on Form DFS-F5-DWC-90 using the applicable
revenue codes.
IV. Ambulatory Surgical Centers shall bill for these products on
Form DFS-F5-DWC-9 using applicable HCPCS codes.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall
enter the applicable HCPCS code in form Field 21 on form revision
2/14/06 and in Field 21 on form revision 1/1/07. The requirement to
enter the HCPCS code when billing for medical equipment or supplies
supersedes the instruction that “the medical supplier is not
required to submit codes” in the Florida Workers’ Compensation
Health Care Provider Reimbursement Manual.
f. When dispensing medical supplies which are not incidental to a
service or procedure:
I. Pharmacists shall bill on Form DFS-F5-DWC-10 and shall enter the
applicable HCPCS code in Field 16 on form revision 2/14/06 and in
Field 21 on form revision 1/1/07.
II. Physicians, physician assistants or ARNPs shall bill on Form
DFS-F5-DWC-9, shall enter the applicable HCPCS code in Field 24D and
attach documentation indicating the actual cost of the supply,
including applicable manufacturer’s shipping and handling. The
requirement to enter the HCPCS code when billing for medical
equipment or supplies supersedes the instruction “under the specific
HCPCS code or 99070” in the Florida Workers’ Compensation Health
Care Provider Reimbursement Manual.
III. Hospitals shall bill on Form DFS-F5-DWC-90 under the applicable
revenue codes.
IV. Ambulatory Surgical Centers shall bill separately for these
products on Form DFS-F5-DWC-9 and shall enter the applicable CPT®
code or HCPCS in Field 24D.
V. Medical Suppliers shall bill on Form DFS-F5-DWC-10 and shall
enter the applicable HCPCS code in Field 16 on form revision 2/14/06
and in Field 19 on form revision 1/1/07. The requirement to enter
the HCPCS code when billing for medical equipment or supplies
supersedes the instruction that “the medical supplier is not
required to submit codes” in the Florida Workers’ Compensation
Health Care Provider Reimbursement Manual.
g. Pharmacists who provide Medication Therapy Management Services
shall bill for these services on a Form DFS-F5-DWC-9 by entering the
appropriate CPT® code(s) 0115T, 0116T or 0117T that represent the
service(s) rendered in form Field 24D, shall enter their Florida
Department of Health license number in Field 33b and shall submit a
copy of the physician’s written prescription with the medical bill.
h. Pharmacists and medical suppliers may only bill on an alternate
to Form DFS-F5-DWC-10 when an insurer has pre-approved use of the
alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFS-F5-DWC-90
shall not be approved for use as the alternate form.
11. Physicians billing for a failed appointment for a scheduled
independent medical examination (when the injured employee does not
report to the physician office as scheduled) shall bill on their
invoice or letterhead. The invoice shall not be a Form DFS-F5-DWC-9,
DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-DWC-90.
12. Health care providers receiving reimbursement under any payment
plan (pre-payment, prospective pay, capitation, etc.) must
accurately complete the Form DFS-F5-DWC-9 and submit the form to the
insurer.
13. Health care providers and other insurer-authorized providers
rendering services reimbursable under workers’ compensation, whose
billing requirements are not otherwise specified in this rule (e.g.
home health agencies, independent, non-hospital based ambulance
services, air- ambulance, emergency medical transportation,
non-emergency transportation services, translation services, etc.)
shall bill on their invoice or business letterhead. These providers
shall not submit the Forms DFS-F5-DWC-9, DFS-F5-DWC-10,
DFS-F5-DWC-11 or DFS-F5-DWC-90 as an invoice.
(c) Bill Completion.
1. Bills shall be legibly and accurately completed by all health
care providers, regardless of location or reimbursement methodology,
as set forth in this section and paragraph (4)(b) of this rule.
2. Billing elements required by the Division to be completed by a
health care provider are identified in specific Form DFS-F5-DWC-9-A
or Form DFS-F5-DWC-9-B (completion instructions), as appropriate for
the date of the revised form, available at the following websites:
a. http://www.fldfs.com/wc/pdf/DWC-9instrHCP.pdf when submitted by
Licensed Health Care Providers;
b. http://www.fldfs.com/wc/pdf/DWC-9instrASC.pdf when submitted by
Ambulatory Surgical Centers;
c. http://www.fldfs.com/wc/pdf/DWC-9instrWHPM.pdf when submitted by
Work Hardening and Pain Management Programs.
3. Billing elements required by the Division to be completed for
Pharmaceutical or Medical Supplier Billing are identified in
specific Form DFS-F5-DWC-10 (completion instructions), as
appropriate for the date of the revised form, available at website:
http://www.fldfs.com/WC/forms.html#7.
4. Billing elements required by the Division to be completed for
Dental Billing are identified in specific Form DFS-F5-DWC-11-A or
Form DFS-F5-DWC-9-B (completion instructions), as appropriate for
the date of the revised form, available at website:
http://www.fldfs.com/WC/forms.html#7.
5. Billing elements required by the Division to be completed for
Hospital Billing are identified in the UB-92 Manual, the UB-04
Manual, Form DFS-F5-DWC-90-B (completion instructions) and
subparagraph (4)(b)4. of this rule.
6. An insurer can require a health care provider to complete
additional data elements that are not required by the Division on
Form DFS-F5-DWC-9 or DFS-F5-DWC-11.