Medical Services FAQ

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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: Reimbursement is made pursuant to an agreed upon contract price or the maximum reimbursement allowance in the fee schedule. Pricing for codes that are not listed in the fee schedule should be addressed at the time of authorization with the carrier.

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.