Fla. Admin. Code Ann. R. 69L-10.016 - Documenting Expenditures for Purposes of Obtaining Reimbursement

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.

(3) Expenditures for Compensation Pursuant to Order. When temporary or permanent disability compensation, permanent impairment benefits, death benefits or wage-loss benefits have been paid pursuant to an order of the Judge of Compensation Claims, which has become final, payment can be documented by providing a copy of the order.

(4) Miscellaneous.

(a) Changes in the rate of compensation shall be established by Notice of Action/Change, DFS DWC-4 forms and by DFS DWC-13 forms, as adopted in rule 69L-3.025, F.A.C., which set forth the number of weeks paid at each rate of compensation. If the DWC-13 forms were not prepared contemporaneously with payment, then computer printouts or ledger sheets may be used to corroborate the change in the compensation rate. Copies of checks are also a sufficient means of documenting changes in the rate of compensation.

(b) Changes in the class of benefits paid by the employer/carrier shall be documented by DFS DWC-4 forms which set forth the date that a prior category of benefits was terminated, as well as the date that a subsequent class of benefits was first paid.

Notes

Fla. Admin. Code Ann. R. 69L-10.016

Rulemaking Authority 440.49(7), 440.591 FS. Law Implemented 440.49 FS.

New 4-19-92, Amended 8-18-93, 12-8-98, Formerly 38F10.016, 4L-10.016, Amended 3-16-09.

New 4-19-92, Amended 8-18-93, 12-8-98, Formerly 38F10.016, 4L-10.016, Amended 3-16-09.