Fla. Admin. Code Ann. R. 69L-7.710 - Definitions

(1) As used in this chapter:

(a) "Accurately Complete" or "Accurately Completed" means the form submitted contains the information necessary to meet the requirements of Chapter 440, F.S., and this rule.

(b) "Adjust" or "Adjusted" means payment is made with modification to the information provided on the bill.

(c) "Ambulatory Surgical Center" or "ASC" is defined in Section 395.002(3), F.S.

(d) "Average Wholesale Price" or "AWP" is as defined in Section 440.13(12)(c), F.S., for medications dispensed on or after July 1, 2013.

(e) "Billing" means the process by which a health care provider submits a medical claim form or medical bill to an insurer, claim administrator or any entity acting on behalf of the insurer, to receive reimbursement for medical services, goods or supplies provided to an injured employee.

(f) "Catastrophic Event" means the occurrence of an event outside the control of a claim administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster or an act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent a claim administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of Chapter 440, F.S., and rule Chapter 69L-7, F.A.C. Programming errors, system malfunctions or electronic data interchange transmission failures that are not a direct result of a catastrophic event are not considered to be a catastrophic event as defined herein. See subsection 69L-7.750(4), F.A.C., for requirements to request approval of an alternative method and timeline for medical report filing with the Division due to a catastrophic event.

(g) "Charges" means the dollar amount billed.

(h) "Charge Master" means for hospitals a comprehensive listing of all the goods and services for which the facility maintains a separate charge, with the facility's charge for each of the goods and services, regardless of payer type and means; for ASCs a listing of the gross charge for each CPT procedure for which an ASC maintains a separate charge, with the ASC's charge for each CPT procedure, regardless of payer type.

(i) "Claim Administrator" means any insurer, qualified servicing entity, third party administrator, claims-handling entity, self-serviced self-insured employer or fund, guarantee fund, or managing general agent responsible for adjusting workers' compensation claims.

(j) "Claim Administrator Code Number" means the number the Division assigns to an Insurer, qualified servicing entity, third party administrator, claims-handling entity, self-serviced self-insured employer or fund, guarantee fund, or managing general agent responsible for adjusting workers' compensation claims.

(k) "Claim Administrator File Number" means the number assigned to the claim file by the claim administrator for purposes of internal tracking.

(l) "Current Dental Terminology" (CDT) means the American Dental Association's reference document containing descriptive terms to identify codes for billing and reporting dental procedures, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(m) "Current Procedural Terminology" (CPT^®) means the American Medical Association's reference document (HCPCS Level I) containing descriptive terms to identify codes for billing and reporting medical procedures and services, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(n) "Date Insurer Paid Bill" and "Date Insurer Paid, Adjusted, Disallowed or Denied" means the date the claim administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits payment to the health care provider or the health care provider representative. If payment is disallowed or denied, "Date Insurer Paid Bill" and "Date Insurer Paid, Adjusted, Disallowed or Denied" means the date the claim administrator or any entity acting on behalf of the insurer mails, transfers or electronically transmits the appropriate notice of disallowance or denial to the health care provider or the health care provider representative. See subsection 69L-7.750(8), F.A.C., for the requirement to accurately report the "Date Insurer Paid Bill."

(o) "Date Insurer Received Bill" means the date that a Form DFS-F5-DWC-9, DFS-F5-DWC-10 (or insurer pre-approved alternate form), DFS-F5-DWC-11, DFS-F5-DWC-90 or the electronic form equivalent is in the possession of the claim administrator or any entity acting on behalf of the insurer. See subsection 69L-7.750(8), F.A.C., for the requirement to accurately report the "Date Insurer Received Bill." If a medical bill meets any of the criteria in paragraph 69L-7.740(11)(g), F.A.C., and possession of the form is relinquished by the claim administrator or any entity acting on behalf of the insurer by returning the medical bill to the provider with a written explanation for the insurer's reason for return, then "Date Insurer Received Bill" shall not apply to the medical bill as submitted.

(p) "Days" means calendar days unless otherwise noted.

(q) "Deny" or "Denied" means payment is not made because the service rendered is for treatment of a non-compensable injury or illness.

(r) "Department" means Department of Financial Services (DFS) as defined in Section 440.02(12), F.S.

(s) "Disallow" or "Disallowed" means payment for a compensable injury or illness is not made because the service rendered has not been substantiated for reasons of medical necessity, insufficient documentation, lack of authorization or billing error.

(t) "Division" means the Division of Workers' Compensation (DWC) as defined in Section 440.02(14), F.S.

(u) "Electronic Filing" means the computer exchange of medical data from a sender to the Division in the standardized format defined in the Florida Medical EDI Implementation Guide (MEIG).

(v) "Electronic Form Equivalent" means the record, provided in the Florida Medical EDI Implementation Guide MEIG to be used when a sender electronically transmits required data to the Division. Electronic form equivalents do not include transmission by facsimile, data file(s) attached to electronic mail, or computer-generated paper-forms.

(w) "Electronically Filed with the Division" means the date an electronic filing has been received by the Division and has successfully passed structural and data-quality edits.

(x) "Entity" means any party involved in the processing, adjudication or payment of medical bills on behalf of the insurer.

(y) "Explanation of Bill Review" (EOBR) means the document used to provide notice of payment or notice of adjustment, disallowance or denial by a claim administrator or any entity acting on behalf of an insurer to a health care provider containing code(s) and code descriptor(s), in conformance with subsection 69L-7.740(13), F.A.C.

(z) "Explanation of Bill Review Code" (EOBR Code) means a code listed in paragraph 69L-7.740(13)(b), F.A.C., that describes the basis for the reimbursement decision of a claim administrator or any entity acting on behalf of the insurer.

(aa) "Florida Medical EDI Implementation Guide (MEIG)" is the Florida Division of Workers' Compensation's reference document containing the specific electronic formats, data elements, and requirements for insurer reporting of medical data to the Division, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(bb) "Healthcare Common Procedure Coding System National Level II Codes (HCPCS)" means the Centers for Medicare and Medicaid Services' (CMS) reference document listing descriptive codes for billing and reporting professional services, procedures, and supplies provided by health care providers, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(cc) "Health Care Provider" is defined in Section 440.13(1)(g), F.S.

(dd) "Home Health Agency" (HHA) is defined in Section 400.462(12), F.S.

(ee) "Home Medical Equipment Provider," sometimes referred to as "durable medical equipment (DME) provider," is defined in Section 400.925(7), F.S.

(ff) "Hospital" is defined in Section 395.002(12), F.S.

(gg) "ICD-9-CM International Classification of Diseases" (ICD-9) is the U.S. Department of Health and Human Services' reference document listing the official diagnosis and inpatient procedure code sets, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(hh) "ICD-10 International Classification of Diseases" (ICD-10) is the 10th Edition of the International Classification of Diseases set of diagnosis and inpatient procedure codes, as incorporated by reference in rule Chapter 69L-8, F.A.C.

(ii) "Implants" means the Surgical Implant(s), the Associated Disposable Instrumentation required for use with the Surgical Implant(s), and shipping and handling, when listed on the implant invoice or certified on the DFS-F5-DWC-90 claim form.

(jj) "Insurer" is defined in Section 440.02(38), F.S.

(kk) "Insurer Code Number" means the number the Division assigns to each individual insurer, self-insured employer, self-insured fund, or guaranty fund financially responsible for the claim.

(ll) "Itemized Statement" means a detailed listing of goods, services and supplies provided to an injured employee, including the quantity and charges for each good, service or supply.

(mm) "Medical Bill" means the document or electronic form equivalent submitted by a health care provider to an Insurer, Service Company/Third Party Administrator or any entity acting on behalf of the Insurer for reimbursement for services or supplies (e.g., DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, DFS-F5-DWC-90 or the provider's usual invoice or business letterhead) as appropriate pursuant to subsection 69L-7.730(2), F.A.C.

(nn) "Medically Necessary" or "Medical Necessity" is defined in Section 440.13(1)(k), F.S.

(oo) "NDC Number" means the eleven-digit National Drug Code (NDC) number, assigned under Section 510 of the Federal Food, Drug, and Cosmetic Act, which identifies the drug product labeler/vendor, product, and trade package size. As used in this rule chapter, when referring to dispensed drugs, "Original Manufacturer's NDC Number" shall mean the NDC Number assigned by the original manufacturer of the underlying dispensed drug; and, "Repackaged NDC Number" shall mean the NDC Number assigned by the repackager/relabeler of the underlying dispensed drug.

(pp) "Nursing Home Facility" is defined in Section 400.021(12), F.S.

(qq) "Pay" or "Paid" means payment is made applying the applicable reimbursement formula to the medical bill as submitted.

(rr) "Physician" is defined in Section 440.13(1)(p), F.S.

(ss) "Primary Physician" means the treating physician responsible for the oversight of medical care, treatment and attendance rendered to an injured employee, to include recommendation for appropriate consultations or referrals.

(tt) "Recognized Practitioner" means a non-physician health care provider licensed by the Department of Health who works under the protocol of a physician or who, upon referral from a physician, can render direct billable services that are within the scope of the recognized practitioner's license, independent of the supervision of a Physician.

(uu) "Report" means any form related to medical services rendered, in relation to a workers' compensation injury that is required to be filed with the Division under rule Chapter 69L-7, F.A.C.

(vv) "Service Company/Third Party Administrator (TPA)" means an entity that has contracted with an insurer for the purpose of providing services necessary to adjust workers' compensation claims on the Insurer's behalf.

(ww) "Sender" means an Insurer, Service Company/TPA, entity or any other party acting on behalf of an Insurer, Service Company/TPA or any entity to fulfill any Insurer responsibility to electronically transmit required medical data to the Division.

(xx) "UB-04 Manual" means the National Uniform Billing Committee Official UB-04 Data Specifications Manual, which is the reference document providing billing and reporting completion instructions for the Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev.11/03/2006), as incorporated by reference in Rule 69L-8.074, F.A.C.

Notes

Fla. Admin. Code Ann. R. 69L-7.710

Rulemaking Authority 440.13(4), 440.15(3)(b), (d), 440.185(5), 440.525(2), 440.591, 440.593(5) FS. Law Implemented 440.09, 440.108(7), 440.13(2)(a), (3), (4), (6), (11), (12), (14), (16), 440.15(3)(b), (d), (f), (5), 440.185(5), (9), 440.20(6), 440.525(2), 440.593 FS.

New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06, 3-8-07, 1-12-10, 10-23-12, 11-6-13, Formerly 69L-7.602, Amended by Florida Register Volume 42, Number 021, February 02, 2016 effective 2/18/2016.

New 1-23-95, Formerly 38F-7.602, 4L-7.602, Amended 7-4-04, 10-20-05, 6-25-06, 3-8-07, 1-12-10, 10-23-12, 11-6-13, Formerly 69L-7.602, Amended 2-18-16.