Under Florida workers’ compensation law, providers can appeal disallowance or adjustment notices by filing a petition with the Department of Workers’ Compensation (DWC) within 45 days.
How to File a Petition
Providers who wish to contest a payment disallowance or adjustment notice must file a petition with the DWC within 45 days of the date of the notice.
Providers must use the Petition For Resolution of Reimbursement Dispute Form to file a petition.
The petition must include all of the following:
- All documentation supporting the allegations stated in the petition, and
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Served by certified mail on the carrier and all affected parties.
If any documentation supporting the petition is missing, the Department may dismiss the petition.
Carrier’s Obligation
Once served, the carrier must respond within 30 days and include all documentation substantiating their disallowance or adjustment. If the carrier fails to respond, it waives its right to object.
Department’s Determination
The Department must issue a written determination within 120 days.
If the Department finds that the carrier improperly adjusted or disallowed payment, the carrier must reimburse the provider within 30 days and may be subject to penalties.
Florida |
Statutes/Rule |
Statute |
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Section |
440.13 Medical Services and Supplies; Penalty for Violations; Limitations |
Subsection Text |
440.13 (7) (a) Any health care provider who elects to contest the disallowance or adjustment of payment by a carrier under subsection (6) must, within 45 days after receipt of notice of disallowance or adjustment of payment, petition the department to resolve the dispute. The petitioner must serve a copy of the petition on the carrier and on all affected parties by certified mail. The petition must be accompanied by all documents and records that support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the department results in dismissal of the petition. (b) The carrier must submit to the department within 30 days after receipt of the petition all documentation substantiating the carrier’s disallowance or adjustment. Failure of the carrier to timely submit such documentation to the department within 30 days constitutes a waiver of all objections to the petition. (c) Within 120 days after receipt of all documentation, the department must provide to the petitioner, the carrier, and the affected parties a written determination of whether the carrier properly adjusted or disallowed payment. The department must be guided by standards and policies set forth in this chapter, including all applicable reimbursement schedules, practice parameters, and protocols of treatment, in rendering its determination. (d) If the department finds an improper disallowance or improper adjustment of payment by an insurer, the insurer shall reimburse the health care provider, facility, insurer, or employer within 30 days, subject to the penalties provided in this subsection.
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