Fla. Admin. Code Ann. R. 69L-24.005 - Maintaining and Providig Records

(1) Pursuant to Section 440.525(1), F.S., the Department may examine and investigate regulated entities as often as is warranted to ensure that they are fulfilling their obligations under Chapter 440, F.S. The Department shall have the power to conduct onsite inspections of claims records and documentation of an insurer, third-party administrator, servicing agent, or other claims-handling entity, and conduct interviews, both sworn and un-sworn, of claims-handling personnel. Insurers, third-party administrators, servicing agents, and other claims-handling entities shall make all claims records, documentation, communication, and correspondence available to Department personnel during regular business hours, pursuant to Section 440.525(3), F.S. All regulated entities shall provide to the Department all information and documentation that is requested for the purposes of monitoring, examining, or investigating the regulated entity's operations and processes. Such information and documentation, including specific data, shall be made available to the Department within 14 calendar days of receipt of any request by the Department unless the Department allows an extension of time.

(2) For examinations or investigations, if the regulated entity maintains hard-copy files, the hard-copy files shall be made available to the Department on or before the date requested by the Department. If the regulated entity maintains electronic files and an examination or investigation is conducted at the regulated entity's offices, a sufficient number of functioning computers shall be made available to the Department for access to the electronic claims documents and information. Requests for information may include, but are not limited to:

(a) The date of notification or knowledge of the injury. "Notification" and "knowledge" are defined in subsections 69L-3.002(23) and 69L-56.002(40), F.A.C.;

(b) The date of initial disability, the eighth day of disability and knowledge of the eighth day of disability;

(c) The date each indemnity payment was mailed to the injured worker, the amount of the payment, and the period of time that was covered in the payment;

(d) The date that Forms DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11 (American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital Billing Form (UB-04), or their electronic equivalents, as incorporated in paragraphs 69L-7.720(1)(a), (b), (c), and (e), F.A.C., were received from the health care provider pursuant to paragraph 69L-7.710(1)(o), F.A.C.;

(e) The date that Forms DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11 (American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital Billing Form (UB-04), or their electronic equivalents, were paid, disallowed, or denied;

(f) The date that Forms DFS-F5-DWC-9 (Health Insurance Claim Form/CMS-1500), DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form and Instructions), DFS-F5-DWC-11 (American Dental Association Dental Claim Form), and DFS-F5-DWC-90 (Hospital Billing Form (UB-04), or their electronic equivalents, were mailed or transmitted to the Department;

(g) The date that Form DFS-F2-DWC-60 (Important Workers' Compensation Information for Florida's Workers' brochure) or DFS-F2-DWC-61 (Informacion Importante De Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida) was mailed to the injured worker;

(h) The date that Form DFS-F2-DWC-65 (Important Workers' Compensation Information for Florida's Employers), or Forms DFS-F2-DWC-66 (Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida), as incorporated in Rule 69L-3.025, F.A.C., was mailed to the employer;

(i) The date that the Employee Notification Letter, as incorporated in subsection 69L-26.004(6), F.A.C., was mailed to the injured worker;

(j) The date that any written request for medical authorization was received and the date that the medical authorization was granted in response to the written request;

(k) Electronic Data Interchange (EDI) transactions and requirements pursuant to Rule 69L-56.001 through 69L-56.500, F.A.C.;

(l) The date that the 120-day notice required under Section 440.20(4), F.S. was mailed;

(m) All diary notes, claim notes, and correspondence available for review during an examination, audit or investigation.

Notes

Fla. Admin. Code Ann. R. 69L-24.005

Rulemaking Authority 440.13(11), 440.185 (9), (10), 440.20(6), 440.525(4), 440.591, 440.593(5) FS. Law Implemented 440.13(11), 440.185, 440.20(6), (8), 440.525, 440.593 FS.

New 1-12-10.

New 1-12-10.