Section 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.Fla. Admin. Code Ann. R. 69L-31.005
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 by Florida Register Volume 47, Number 139, July 20, 2021 effective 8/2/2021.New 11-28-06, Formerly 59A-31.005, Amended 8-2-21.