Fla. Admin. Code Ann. R. 69L-31.005 - Written Determinations
(1) The
Department will render a written determination on whether the Carrier properly
adjusted or disallowed payment pursuant to Section
440.13(7)(c),
F.S., by relying on the Petition Form, Response Form, and all supporting
documentation submitted to the Department by the Petitioner and the Carrier to
support their respective positions. The Department will use an Expert Medical
Advisor (EMA), in accordance with Section
440.13(9)(b),
F.S., to assist in resolving Reimbursement Disputes associated with the
disallowance or adjustment of payment based upon Medical Necessity of the
services in the Notice of Disallowance or Adjustment when both the Petitioner
(pursuant to paragraph
69L-31.003(3)(e),
F.A.C.) and Carrier (pursuant to paragraph
69L-31.004(3)(b),
F.A.C.) have provided documentation to support their respective decisions on
the Medical Necessity of the services. If an EMA is utilized by the Department,
all forms and documentation received pursuant to Rules
69L-31.003 and
69L-31.004, F.A.C., will be
forwarded to the EMA.
(2) In its
written determination, the Department will address the specific line item(s) in
the Notice of Disallowance or Adjustment that the Petitioner contends were
improperly disallowed or adjusted.
Notes
Rulemaking Authority 440.13(7)(e), 440.591 FS. Law Implemented 440.13(7), (9), (11) FS.
New 11-28-06, Formerly 59A-31.005, Amended 8-2-21.
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