In Florida, providers must obtain prior authorization before delivering any non-emergency treatment to injured workers. In certain circumstances, claims administrators may deny authorization.
Below are Florida workers’ compensation requirements under which authorization or payment for treatment may be denied.
Authorization Denials
A claims administrator may deny prior authorization for treatment or services under the following circumstances:
- Unauthorized Provider or Facility: The provider or medical facility is not authorized to deliver care.
- Non-Compliance with Statutory Protocols: The requested treatment does not align with Florida workers’ compensation statutes or medical protocols.
-
Judicial Ruling: A Judge of Compensation Claims determines that the requested service is unnecessary or not compensable.
Important: Providers must ensure prior authorization is obtained and that the requested services meet all statutory and regulatory requirements before treating an injured worker.
Carrier Oversight
Even after obtaining prior authorization, claims administrators may disallow reimbursement for the following reasons:
- Overutilization: Excessive or unnecessary services beyond the approved scope.
- Billing Errors: Incorrect, incomplete, or non-compliant billing submissions.
Providers should maintain detailed documentation, follow all prior authorization protocols, and ensure billing accuracy to avoid reimbursement denials.
Florida |
Statute/Rule |
Statute |
|
Section |
440.13 Medical Services and Supplies; Penalty for Violations; Limitations |
Subsection Text |
440.13 (3) (a) As a condition to eligibility for payment under this chapter, a health care provider who renders services must receive authorization from the carrier before providing treatment. This paragraph does not apply to emergency care.
440.13 (3) (i) Notwithstanding paragraph (d), a claim for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, X-ray examinations, or special diagnostic laboratory tests that cost more than $1,000 and other specialty services that the department identifies by rule is not valid and reimbursable unless the services have been expressly authorized by the carrier, unless the carrier has failed to respond within 10 days to a written request for authorization, or unless emergency care is required. The insurer shall authorize such consultation or procedure unless the health care provider or facility is not authorized, unless such treatment is not in accordance with practice parameters and protocols of treatment established in this chapter, or unless a judge of compensation claims has determined that the consultation or procedure is not medically necessary, not in accordance with the practice parameters and protocols of treatment established in this chapter, or otherwise not compensable under this chapter. Authorization of a treatment plan does not constitute express authorization for purposes of this section, except to the extent the carrier provides otherwise in its authorization procedures. This paragraph does not limit the carrier’s obligation to identify and disallow overutilization or billing errors. |
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