Florida DWC Posts Explanation Of Bill Review FAQs

Orlando, FL (WorkersCompensation.com) - The Florida Division of Workers' Compensation posted explanations of bill review to commonly frequently asked questions. An EOBR is an Explanation of Bill Review; it is the notice of payment or notice of adjustment, disallowance or denial sent by an Insurer, service company/third party administrator or any entity acting on behalf of an Insurer to a health care provider containing code(s) and code descriptor(s), in conformance with subsection (5) of 69L-7.602, Florida Administrative Code.

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 title is optional. 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 69L-7.602, 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 69L-7.602(5)(o), 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 Insurer specific payment/denial explanations?
Answer: Yes. Each line item on an EOBR must contain at least one EOBR Code authorized in 69L-7.602(5)(o), 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 69L-7.602(5)(q), 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 69L-7.602(5), Florida Administrative Code apply to this situation?
Answer: Yes. All bills that fall under Florida Workers' Compensation laws must comply with 69L-7.602(5), 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 69L-7.602(5), Florida Administrative Code.

Question: Is both the Third Party Administrator's and the Insurer's information required on an EOBR?
Answer: The Insurer's information is required on all EOBRS, but the Third Party Administrator's information is not generally required, but may be listed. Per 69L-7.602(5)(q), Florida Administrative Code, the specific Insurer's name, address, and Division issued Insurer number is required on an EOBR. If the Insurer has indentified the Third Party Administrator as the entity designated to receive service on behalf of the "Insurer and all affected parties" for the purpose of receiving the petitioner's service of a copy of a petition for reimbursement dispute resolution, the Third Party Administrators' Name and mailing address must appear on the EOBR.

Question: If an Insurer has a Third Party Administrator, should the Third Party Administrator's mailing address and division issued number be used in place of the Insurer's information?
Answer: No. Per 69L-7.602(5)(q), Florida Administrative Code, the specific Insurer's name, address, and Division issued Insurer number are required on an EOBR. If the Insurer has indentified the Third Party Administrator as the entity designated to receive service on behalf of the "Insurer and all affected parties" for the purpose of receiving the petitioner's service of a copy of a petition for reimbursement dispute resolution, the Third Party Administrators' 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 69L-7.602(5)(o), Florida Administrative Code.

Question: Does an EOBR require the injured employee's Social Security Number?
Answer: No. Please refer to 69L-7.602(5)(q), Florida Administrative Code.

Question: Does the Insurer's name and address have to relate to the actual Insurer, or can it be their TPA?
Answer: The name and address of the actual Insurer is required to appear on the EOBR. Please refer to 69L-7.602(5)(q), Florida Administrative Code.

Question: Is the Insurer or Third Party Administrator responsible for the conveyance of the EOBR?
Answer: The Insurer is responsible for communicating its reimbursement decision to the health care provider. This is done via the EOBR. The Insurer may delegate this duty to the Third Party Administrator; however, the Insurer 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 a paper or electronic remittance is up to the respective parties. However, if the parties agree that the electronic remittance will serve as the EOBR, that electronic remittance must include the same elements as a compliant EOBR, per 69L-7.602(5)(q), 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 arrives in a format other than a valid bill, an EOBR may be used.

Question: Are there guidelines for determining importance of EOBR Codes?
Answer: An Insurer 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 Insurer's most important reason to least important reason. This matter of importance is determined by the Insurer or its designee. Please refer to 69L-7.602(5)(o), Florida Administrative Code.

Question: What is the correct value to put for the Insurer name when a bill is related to a Self-Insured Entity?
Answer: It would be proper to provide the name of the Self-Insured Entity along with its address and Division issued Insurer number. Pursuant to s. 440.02(38), F.S., a Self-Insured Entity is an Insurer.

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. An Insurer can select their own EOBR format as long as it meets all requirements found in 69L-7.602(5) , 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 69L-7.602(5)(q), Florida Administrative Code. The statement must appear on the EOBR; however, each insurer 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. However, it is possible that the Division would work with the Insurer on a case by case basis. If you have a specific concern about whether or not your EOBR is compliant, the Bureau of Monitoring and Audit is happy to review and comment on any entity's EOBR. Please refer to the contact information at the end of these FAQs.

Question: Can an Insurer use the bottom of a check as an EOBR as long as it meets all requirements?
Answer: Yes. Please keep in mind the EOBR must be legibly reproduced upon request.

Question: Does an EOBR have to be a separate document than the reimbursement check?
Answer: No. There is nothing that prohibits an Insurer from using the check stub or remittance statement as the EOBR provided it contains all of the elements of a compliant EOBR. Please keep in mind the EOBR must be legibly reproduced upon request.

Question: If the Insurer 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: Is it permissible to use a key or legend to associate a note with a particular line item if you can't mingle it with the EOBR codes?
Answer: Yes, as long as the EOBR meets all other requirements.

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.

Question: Is it permissible to print more than 3 EOBR Codes?
Answer: 69L-7.602(5)(o), Florida Administrative Code, states that up to three EOBR codes may be utilized for each line item billed.

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