Question: What is an EOBR?

Answer: An EOBR is an Explanation of Bill Review; it is the notice of payment or notice of adjustment, disallowance or denial sent by a carrier, service company/third party administrator or any entity acting on behalf of a carrier to a health care provider (provider) containing code(s) and code descriptor(s), in conformance with paragraph 69L-7.740(13), Florida Administrative Code.

Question: What is the purpose of the EOBR?

Answer: The EOBR is the carrier’s written official notification to the provider of the reimbursement decisions to pay, disallow or adjust reimbursement. The carrier is required to explain the reimbursement for each billed line item by using the EOBR codes (listed in Rule within subsection 69L-7.740(13)(b), F.A.C.) that best describe the carrier’s reimbursement decision.

Question: Is the term "Explanation of Bill Review" or acronym "EOBR" required to be on the form, verbatim or is the title optional?

Answer: The term "Explanation of Bill Review" is preferred by the Division, but it is not a requirement. If the document was titled something differently but still met the requirements of Rule 69L-7.740, Florida Administrative Code, if it was the document given to providers to convey the disposition decision, and the document was presented as the EOBR, the Division would accept it as such.

Question: May an EOBR contain unique, in-house EOBR Explanation Codes?

Answer: Yes. Each line item on an EOBR must contain at least one EOBR Code authorized in paragraph 69L-7.740(13)(a), Florida Administrative Code. All Rule authorized codes must be primary and superior to any other internal code. After this requirement has been fulfilled, internal and unique codes may be used and should be presented in a separate and distinct manner.

Question: Do EOBR codes and descriptors have to be placed on the EOBR ahead of carrier specific payment/denial explanations?

Answer: Yes. Each line item on an EOBR must contain at least one EOBR Code authorized in paragraph 69L-7.740(13)(b), Florida Administrative Code. All Rule authorized codes must be primary and superior to any other internal code. After this requirement has been fulfilled, internal and unique codes may be used and should be presented in a separate and distinct manner.

Question: Is it permissible to use a separate and distinct portion of the EOBR to provide unique codes and descriptions for reductions in addition to the state specific EOBR codes and descriptions?

Answer: Yes, as long as all other requirements under subsection 69L-7.740(14), Florida Administrative Code are met, it is permissible.

Question: Some of our clients request that we process bills according to the provider state where services are rendered rather the jurisdiction state. Do the Requirements in Rule 69L-7.740, Florida Administrative Code apply to this situation?

Answer: Yes. All bills that fall under Florida Workers' Compensation laws must comply with Rule 69L-7.740, Florida Administrative Code.

Question: What if a provider does not want an EOBR or a Florida specific EOBR?

Answer: An EOBR is still required. All bills that fall under Florida Workers' Compensation laws must be responded to in compliance with Rule 69L-7.740, Florida Administrative Code.

Question: What is a Carrier?

Answer: "Carrier" means any person or fund authorized under section 440.38, F.S. to insure under this chapter and includes a self-carrier, and a commercial self-insurance fund authorized under section 624.462, F.S.

Question: Is the actual carrier information required on an EOBR for the injured employee?

Answer: The actual carrier’s information for the injured employee’s claim is required on all EOBRS. Per subsection 69L-7.740(14), Florida Administrative Code, the specific carrier’s name, address, and Division issued carrier number is required on an EOBR.

Question: If a carrier has a claim administrator, should the claim administrator’s mailing address and Division issued number be used in place of the carrier’s information?

Answer: No. Per subsection 69L-7.740(14), Florida Administrative Code, the specific carrier's name, address, and Division issued carrier number are required on an EOBR. If the carrier has identified the claim administrator as the entity designated to receive service on behalf of the carrier and all affected parties for the purpose of receiving the petitioner’s service of a copy of a petition for reimbursement dispute resolution, the claim administrator’s name and mailing address must appear on the EOBR.

Question: Is an employer's name and address required on an EOBR?

Answer: No, please refer to subsection 69L-7.740(14), Florida Administrative Code.

Question: Should an EOBR reflect identifying information for the injured employee?

Answer: The DWC prefers identifying information for the injured employee on EOBRs.

Question: Is the carrier or claim administrator responsible for the conveyance of the EOBR?

Answer: The carrier is responsible for communicating its reimbursement decision to the provider. This is done via the EOBR. The carrier may delegate this duty to the claim administrator; however, the carrier continues to be ultimately responsible for ensuring that the EOBR is sent to the provider.

Question: Is an electronic version of the EOBR acceptable?

Answer: Yes. Whether or not a provider receives the EOBR in a paper or electronic format is up to the respective parties. However, if the parties agree that the electronic  format will serve as the EOBR, that electronic  format  must include the same elements as a compliant EOBR, per subsection 69L-7.740(14), Florida Administrative Code. In addition, the EOBR must be legibly reproduced upon request.

Question: May an EOBR be used to respond to reconsideration requests?

Answer: An EOBR must be used if the reconsideration is in the form of a valid bill. If a reconsideration is not requested via a valid bill, an EOBR may be used.

Question: Are there guidelines for determining importance of EOBR Codes?

Answer: A carrier may use up to three (3) EOBR codes and descriptors per billed line item to explain a reimbursement decision. The EOBR codes should be listed in order from the carrier's most important reason to least important reason. This matter of importance is determined by the carrier or its designee. Please refer to paragraph 69L-7.740(13)(a), Florida Administrative Code.

Question: Can the Division provide examples of valid EOBRs or a blank EOBR form?

Answer: The Division does not have a standard format for EOBRs. A carrier can select their own EOBR format as long as it meets all requirements found in Rule 69L-7.740, Florida Administrative Code.

Question: Must an EOBR state that it constitutes notice of disallowance or adjustment of payment within the meaning of section 440.13(7), F.S.?  Where on the EOBR must this statement be placed?

Answer: Yes, please refer to paragraph 69L-7.740(14), Florida Administrative Code. The statement must appear on the EOBR; however, each carrier may choose the location of the statement.

Question: If there is a system limitation that does not allow for population of the 'parenthetical' requirements in the EOBR description, can the additional information be accounted for in separate, system-generated messages?

Answer: Yes. System limitations may be overcome via the use of common abbreviations and suffixes, as well as by cross-reference within the parenthetical to carrier unique code or index systems. A carrier unique code could be placed in the parentheses and the information could be conveyed elsewhere on the EOBR.

Question: What if one of the elements required for an EOBR cannot be possibly met due to database constrictions such as identifying and labeling the integral component or inclusive component in an EOBR description?

Answer: The EOBR would be non-compliant. If you have a concern about whether your EOBR is compliant, the Bureau of Monitoring and Audit is happy to review and comment on any entity's EOBR. Please contact Workers.CompMedService@myfloridacfo.com.

Question: If the carrier needs to add a note along with the state EOBR code, can the note have a code associated with it?

Answer: Yes, as long as the EOBR meets all other requirements. All rule authorized codes must be primary and superior to any internal code. After this requirement has been fulfilled, internal and unique codes may be used and should be presented in a separate and distinct manner.

Question: If a bill was subject to PPO network reductions and the appropriate EOBR code was used at the line level, is it appropriate to exclude the parenthetical stating the PPO network name from that EOBR code as long as there is a distinct place (box) on the form that indicates the PPO name, address, information?
Answer: If the PPO's name was explicitly indicated as such, it would meet the requirements.

Provision of Medical Services; Authorization

Question: What services are authorized under the Florida Workers’ Compensation system?

Answer: Any service that is medically necessary to treat the compensable condition may be authorized by the workers’ compensation carrier. However, the service or treatment must not be investigational or experimental in nature.

Question: What does medically necessary or medical necessity mean?

Answer: "Medically necessary" or "medical necessity" is defined in paragraph 440.13(1)(k),F.S. as any medical service or medical supply which is used to identify or treat an illness or injury, is appropriate to the patient's diagnosis and status of recovery, and is consistent with the location of service, the level of care provided, and applicable practice parameters. The service should be widely accepted among practicing health care providers, based on scientific criteria, and determined to be reasonably safe. The service must not be of an experimental, investigative, or research nature.

Question: Are there limitations on the level, duration, intensity and frequency of services rendered to an injured employee?

Answer: No. If a service is medically necessary and such treatment conforms to the standards of care that require "all treatment [to] be inherently scientifically logical”, and the evaluation or treatment procedure must match the documented physiologic and clinical problem. Treatment shall match the type, intensity, and duration of service required by the problem identified."

Question: Is a provider required to obtain prior authorization to treat an injured employee?

Answer: Yes, except in emergency situations. As a condition of reimbursement, a provider must obtain authorization from the workers’ compensation carrier prior to rendering medical treatment and services. Prior authorization is not required to render emergency treatment.

Documenting Medical Condition Status/Proposed Treatment Plans

Question: What documentation is required to be submitted by the provider to the workers’ compensation carrier to report the medical status and treatment recommended or rendered to the injured employee?

Answer: The provider must submit a Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form DFS-F5-DWC-25, to request authorization of the treatment plan, referral to specialists, and to communicate the injured employee’s medical condition and return to work status.

Question: Under what condition can the workers’ compensation carrier not approve the provider’s treatment plan?

Answer: A workers’ compensation carrier must authorize a provider’s treatment plan unless the health care provider or facility is not authorized or licensed, unless such treatment is not in accordance with the standards of care provisions established in this chapter, or unless a judge of compensation claims has ordered that the consultation, treatment or procedure is not medically necessary, not in accordance with the standards of care provisions established in this chapter, or otherwise not compensable under this chapter.

Question: May a provider refer an injured employee to another provider without prior authorization from a workers’ compensation carrier?

Answer: No, a provider may not refer the employee to another provider, diagnostic facility, therapy center, or other facility without prior authorization from the carrier, except when emergency care is needed.

Monitoring Health Care Provider Compliance with Established Policies and Standard of Care Requirements

Question: Are providers required to follow any specific guidelines in the provision of medical treatment and services to injured employees?

Answer: Providers are required to follow the Standards of Care provisions in subsection 440.13(15), F.S., when rendering medically necessary treatment and care to injured employees.

Question: How are rendered services monitored to ensure compliance with applicable statutory and rule requirements?

Answer: All medical billing claims submitted to a workers’ compensation carrier for reimbursement are filed with the Division by the workers’ compensation carrier. The Division monitors the medical claims data to ensure providers are not in violation of applicable administrative rules related to the standards of care and the billing and reporting of services.
The Division may also conduct a medical record or file review to validate the accuracy of the medical claims data filed by workers’ compensation carriers.

Question: What are provider violations?

Answer Violations are providers non-compliance with the requirements of Chapter 440, F.S. and Division rules, which include: improper billing pursuant to Rule 69L- 7.740, Florida Administrative Code; failing to submit medical records and reports pursuant to subsections 440.13(4)(a) and (c), F.S.; failing to refund an overpayment of reimbursement, pursuant to subsection 440.13(11)(a), F.S.; collecting or receiving payment from an injured employee in violation of subsection 440.13(13), F.S.; or failing to follow the standards of care, pursuant to subsection 440.13(15), F.S., including overutilization of services.

Question: Who can file a provider violation referral or complaint?

Answer: A workers’ compensation carrier, injured employee, provider or a Division employee can file a  provider violation referral or complaint online, via email or regular mail at:
Health Care Provider Violation Website or
workers.compmedservice@myfloridacfo.com or
Division of Workers’ Compensation, Medical Services Section, 200 East Gaines Street, Tallahassee, FL 32399-4232.

Question: What are the consequences for non-compliance with established administrative rules and policies?

Answer: The Division may impose administrative penalties and sanctions pursuant to subsections 440.13(8) and (11), F.S. for violations of Chapter 440, F.S. and applicable rules. These actions may include but are not limited to:

• An order of the department barring the provider from payment under this chapter;
• Deauthorization of care under review;
• Denial of payment for care rendered in the future;
• Decertification of a health care provider certified as an expert medical advisor under subsection (9)
• An administrative fine assessed by the department in an amount not to exceed $5,000 per instance of overutilization or violation;
• Notification of and review by the appropriate licensing authority pursuant to s. 440.106(3), F.S.

Expert Medical Advisors

Question: Does the Florida Workers’ Compensation system utilize physicians to render expert professional opinions in legal proceedings?

Answer: Expert Medical Advisors (EMAs) are utilized by the Division to provide peer review or expert medical consultation, opinions, and testimony to the department or to a judge of compensation claims in connection with resolving disputes relating to reimbursement, differing opinions of health care providers, and health care and physician services rendered under this chapter, including utilization issues.

Question: What are the qualification requirements to become certified as an EMA?

Answer: To qualify for EMA certification, a physician must, at a minimum, hold clear and active licensure from the Florida Department of Health;  hold current board certification or board eligibility applicable to the specialty for which the applicant seeks certification and meet all other eligibility requirements provided in Rule Chapter 69L-30, F.A.C.

Question: How does a physician apply for EMA certification?

Answer: A physician must meet the eligibility requirements provided in Rule 69L-30, F.A.C. and complete the online EMA certification process available through the DWC Medical Services Web Portal.

Question: How does a provider file a complaint if they disagree with the amount of reimbursement issued by the workers’ compensation carrier?

Answer: If the provider disagrees with a workers’ compensation carrier’s reimbursement decision, the provider may contest the reimbursement by filing a Petition for Resolution of Reimbursement Dispute pursuant to Rule 69L-31, F.A.C. with the Division’s Medical Services Section.

 Question: Is there a time limit when the provider may file a Petition for Resolution of Reimbursement Dispute?

Answer: Yes. The provider must file a Petition for Resolution of Reimbursement Dispute with the Medical Services Section within 45 days of receiving a notice of disallowance or adjustment of payment (Explanation of Bill Review, EOBR) from the carrier. Rule Chapter 69L-31, F.A.C. provides the specific requirements to be met by the provider when filing a petition.

 Question: What constitutes a valid petition?

Answer: The petitioner must:

• Serve the petition on the Division of Workers’ Compensation, Medical Services Section within 45 days of receipt of a notice of payment, adjustment to payment or disallowance of payment; and
• Serve a copy of the petition and all documentation submitted with the petition to the workers’ compensation carrier by United States Postal Service certified pursuant to Rule 69L-31.007, F.A.C.; and
• Submit all required documentation, pursuant to Rule 69L-31.005, F.A.C.; and
• Submit all documentation needed to substantiate the petitioner’s allegations.

Question: Is the provider required to notify the carrier that a petition has been filed?

Answer: Pursuant to subsection 440.13(7)(a), Florida Statutes and Rule 69L-31.007, F.A.C., the provider is required to send, by United States Postal Service certified mail, the carrier a copy of the petition and all accompanying documentation filed with the Division of Workers’ Compensation, Medical Services Section.

 Question: What is a Notice of Deficiency?

Answer: A Notice of Deficiency (NOD) document will be issued by the Division of Workers’ Compensation, Medical Services Section (MSS) in response to a petition received with omissions of required documentation or omission of entries on the petition form. The submitter will have 10 days from date of receipt of the NOD to submit curative documentation to the MSS and serve a copy of the curative documentation upon the carrier via United States Postal Service certified mail.

 Question: What will happen if the petitioner fails to cure the deficiency, fails to respond within 10 days from receipt of the NOD, or fails to serve a copy of the curative documentation on the carrier?

Answer: The petition deficiencies are deemed uncured and the petition is dismissed.

 Question: What is the purpose of the Explanation of Bill Review (EOBR)?

Answer: The EOBR is the carrier’s written official notification to the provider of the reimbursement decisions to pay, disallow or adjust reimbursement. The carrier is required to explain the reimbursement for each billed line item by using the EOBR codes (listed in Rule within subsection 69L-7.740(13)(b), F.A.C.) that best describe the carrier’s reimbursement decision.

 Question: Can a determination rendered by the Division of Workers’ Compensation, Medical Services Section be contested by either party to the reimbursement dispute?

Answer: The provider or the carrier, or the entity designated to represent the provider or carrier, may contest the Division’s determination by filing a request for administrative hearing under Chapter 120, Florida Statutes.

Non-Payment Issues

 Question: What can a provider do if a carrier fails to respond to the provider’s request for payment of services?

Answer: A provider can file a non-payment complaint with the Division of Workers’ Compensation, Medical Services Section for a determination of the provider’s entitlement to reimbursement.

 Question: What is a non-payment complaint?

Answer: A non-payment complaint is a provider’s allegation that a medical bill remains unpaid by the carrier after 45 days or more from the date an accurately completed bill was submitted to the carrier. To qualify as a non-payment issue the carrier must have failed to reimburse for billed services, failed to issue an EOBR to explain reason for non-payment, failed to acknowledged receipt of the medical bill, and/or failed to file a form DFS-F2-DWC-12 form with the Division.

 Question: How does the provider file a non-payment complaint?

Answer: A provider can file a non-payment complaint 46 days or more from the date the carrier received the accurately completed medical bill when no notice of payment or disallowance is received. The complaint may be faxed to (850) 354-5100, emailed to WCMedBillNonpay@myfloridacfo.com or mailed to the Division of Workers’ Compensation, Medical Services Section at 200 East Gaines St.; Tallahassee, FL 32399-4232.

Billing and Reporting Medical Services and Treatment

Question: Are there any time-frame requirements for submitting medical bills to a carrier?

Answer: No, there are no statutory time-frame requirements for submitting a medical bill to a carrier. However, the provider should submit a bill as soon as possible after the services are rendered. It is important that the carrier receive the necessary medical reports and bills quickly to ensure the injured employee receives appropriate benefits in a timely manner.

Question: What billing forms are used to bill rendered medical services and treatment?

Answer: Physician and other licensed recognized practitioner services, including oral and maxillofacial services, work hardening and pain management services are reported and billed on the form DFS-F5-DWC-9 (CMS 1500); Medical Supplies and Drugs dispensed by pharmacies and home medical equipment providers (durable medical equipment suppliers) are reported and billed on the form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Equipment and Supplies Form); Dental services are reported and billed on the form DFS-F5-DWC-11 (ADA Claims Form); Facility services (to include Hospital, ASC, Nursing Homes, and Home Health Care) are reported on the form DFS-F5-DWC-90 (UB-04).

Question: Who is responsible for payment of services rendered to injured employee for a compensable injury?

Answer: The carrier is responsible for the payment of all authorized, medically necessary services.

Question: How is reimbursement for services determined?

Answer: Reimbursement is based on the policy in effect on the date of service for the specific provider type rendering the billed services. The Florida Workers’ Compensation system has established maximum reimbursement allowances (MRAs) for each provider type eligible to render services under this program: physicians, recognized practitioners, pharmacies, hospitals, and Ambulatory Surgical Centers. Nursing Homes, Home Health Agencies, and Home Medical Equipment (HME) providers are reimbursed under a contractual agreement between the provider and the carrier at the time of authorization for the service.

Question: Is the health care provider required to submit medical records and reports with the medical bill as a condition of reimbursement?

Answer: The carrier may disallow reimbursement for services when the provider fails to submit the DFS-F5-DWC-25 which documents the request for authorization of the billed services as required by rule. A carrier may also disallow reimbursement for services when the provider fails to submit those documents listed in the reimbursement manual(s) or other forms of documentation specifically requested by the carrier in writing at the time of authorization.
Examples may be:

• Itemized statement
• Operative reports for surgical procedures
• Implant certification/documentation
• DWC-25, when required by rule
• Documentation to support medical necessity of care, services or treatment
• Medication administration records

Question: May a provider require a carrier to reimburse an amount different from the maximum reimbursement allowance (MRA) provided in the applicable reimbursement manual?

Answer: A provider may be reimbursed an amount greater or lesser than the MRA if the provider and carrier enter into a written reimbursement contract.

Question: How long does a carrier have after the receipt of a medical bill to respond to the provider?

Answer: A carrier is required by paragraph 440.20(2)(b), Florida Statutes, to pay, disallow, adjust or deny reimbursement of an accurately completed medical bill within 45 days of receipt. Additionally, the carrier shall provide written notification of the reimbursement decision (Explanation of Bill Review, EOBR) to the provider, pursuant to Rule 69L- 7.740, F.A.C.

Question: When completing the Form DWC-9 for services provided by recognized health care practitioner to an injured employee, what number is entered in Field 33b?

Answer: All treatment, care and attendance services are to be billed by the recognized health care provider who directly rendered the billable service. However, special billing requirements found in subsection 69L- 7.730(2), F.A.C. requires recognized providers except for physician assistants and advanced registered nurse practitioners, who are salaried employees of an authorized treating physician to bill under the employing physician’s alpha-numeric Florida Department of Health license number or unique license number format.

Question: If a procedure code is valid in the CPT/HCPCS code books but is not listed in the Division's fee schedules, how do I bill and get reimbursed?

Answer: Valid CPT/HCPCS codes not listed in current fee schedules are reimbursed as "By Report" codes. Submit the medical documentation to the carrier for pricing and reimbursement.

Question: There appears to be a conflict in the billing and reporting requirements for compound drugs.  How should each individual component contained in the compound medication be listed by the provider?

Answer: A compound drug is billed on a single line item on the DWC-9 or the DWC-10 forms using the unique Florida Workers’ Compensation code “COMPD” and the total charge for the compounded drug.

The individual NDC numbers for each of the compound drug components is not listed on the forms.  A separate document accompanying the bill lists each component of the compounded medicine and the associated NDC numbers(s), if applicable as not all compounded components have an NDC number.