This action might not be possible to undo. Are you sure you want to continue?
By: Rhina CBustamante
Table of Contents: Page 3- About Me Page 4- How to work a PIP Claim- Initial Contact & Police Reports Page 5- How to work a PIP Claim- ISO Search, Investigation Tool & Letters Sent to Claimants Page 6- How to work a PIP Claim- continuation Letters Sent to Claimants, Providers & Medical Bills Page 7- How to work a PIP Claim- continuation Medical Bills, Death Benefits & Demands Page 8- How to work a PIP Claim- continuation of Demands Page 9- How to work a PIP Claim- PIP Adjuster Dictionary Page 10- How to work a PIP Claim- Auto Policy Coverage’s Page 11-16 – How to work a PIP Claim- Florida Statute 627.736 Important Sections for PIP Adjuster’s Page 17- How to work a PIP Claim- Billing CMS 1500 Form Page 18- Reference Page
Written by Rhina C. Bustamante- Request Permission Before Copying
About me: Insurance is a field that offers so many wonderful career opportunities. I obtained my Accredited Claims Adjuster Designation March of 2004. I also hold a Bachelors’ Degree in Legal Studies, an Associates’ Degree in Medical Insurance Billing & Coding, and most recently completed the Healthcare in Risk Manager Course. I have worked for insurance companies as a PIP and Litigation PIP Adjuster, a wonderful family-oriented law firm as a Legal Assistant and the States department of health as a Medical Malpractice Investigator. I write this manual for you, my adjuster colleagues! Insurance is my passion and I know walking up the insurance career ladder will not be easy but YOU will get there. I invite you to read on and allow yourself to absorb this information and use it as a guide. Remember every insurance carrier writes different types of insurance policies; but in Florida they all offer basic coverage which contains PIP, PD and BI. If additional coverage’s are available to purchase, individuals may do so by contacting an agent. Once you feel comfortable, find your way and adjust claims in your rhythm while following your company’s rules and guidelines and always to the standards set in Florida Statute. Don’t forget the claims assigned in your name represent you and your adjuster license! Be respectful, mindful and courteous to everyone including your colleagues. You will learn all you need to know with regard to PIP on the job, hands-on, ask many questions and take plenty notes. I wish you luck and success in your insurance endeavors! Feel free to reach me via email (comments and/or questions are always welcome) @ firstname.lastname@example.org. Every investigation starts with “What, who, where, when and how”. What= Accident Who= Claimants involved in loss Where= Where did this accident occur When= When did this accident occur How= How did this accident occur You are the Personal Injury Protection (PIP) claims adjuster and your goal is to ensure that the injuries, treatment, and facts all add up. As you will be dealing with the medical aspect of a claim, invest in a medical dictionary so you can familiarize yourself with medical terms. Every insurance company works differently; some insurance carriers have certain personnel assigned to certain tasks and the adjuster is just set in place to deny or clear coverage, where other insurance carriers have the insurance adjuster responsible for all aspects of the PIP claim from mailing letters, submitting request for payments, entering the bills into a system, responding to demand letters (many times PIP Litigation Adjuster’s will handle the claim once there is a demand (pre-suit)), etc.
Written by Rhina C. Bustamante- Request Permission Before Copying
You will need to ask them some serious questions. if there were injuries who was injured. who was driving the vehicle. etc. If you have a police report number and what jurisdiction responded to the scene. you need to know who was driving the vehicle to see if they are listed on the policy written by your insurance company. you need to know if there were any passengers (you will need to know if they are related to your insured and if they live with your insured-refer to Florida Statute 627. it is just a conversation where you are trying to help them help you! Ask them what happened (for example: who was involved in the accident. 2) Police Reports: Check to see if a police report was provided. the provider’s office where the names insured and/or claimant is treating. insurance carrier for the other party(s) involved in the accident. and lastly you need to know if the vehicle has been repaired and by whom (body shop). were there any passengers.Request Permission Before Copying 4 . what vehicle was involved in the accident. who was at fault for the accident. you need to know if there were injuries and if those injured are treating or were treated by any medical provider. follow your company’s rules and guidelines as to how they would like you to proceed in obtaining a copy of the police report. 1) Initial Contact: Contact the insured to obtain all the facts concerning the accident/loss. If one has not been provided.732 for definitions of “named insured” and “relative residing in the same household”). was law enforcement called. and/or directly from the Written by Rhina C. Note: Always send out a PIP application package to the named insured and claimants involved in loss requesting PIP coverage. such as photos of the vehicle insured by your insurance carrier). You must contact the attorney’s office! If the insured and/or claimant that are represented should contact you via telephone kindly advise them to contact their attorney! a) Why you inquire to the facts of the accident/loss: You need to know what vehicles were involved in the accident to ensure the vehicle is insured by your insurance company. were there any injuries. You can request a copy from the following: the named insured and/or claimant.How to work a PIP claim: As soon as you have an opportunity ask your manager or supervisor for a copy of the company’s policy jacket (trust me this will come in handy). you need to know if any of the claimants lost time from work (loss wages) due to the accident. the named insured and/or claimant’s attorney. you need to know if there was or were any other vehicles involved in this accident that way you can contact the insurance carrier who insures those or that vehicle (contact the other insurance carrier adjusters and see what information they can share with you.) Note: If you receive a letter of representation from an attorney indicating they represent your insured or any claimant. do not contact the insured and/or claimant. did anyone go to the hospital. don’t be scared. check to see if the police report number was provided by the person who reported the accident to your insurance company.upon the initial phone call made by you to determine facts of the accident. Bustamante.
Florida Law requires any licensed individual who has a vehicle registered in their name obtain automobile insurance! Note: List in your notes the “possible” drivers. 3) ISO Searches: Database used to search for any PIP. when any additional amounts are made to the policy the amount is called an “additional premium”. Inquire with your manager or supervisor to see what company they use for these type of searches. ask you manager or supervisor. and lastly 3rd run the vehicles attached to the address. For further inquiries regarding ISO searches and the database which you will you use for these searches. you would need to inquire with the named insured to rule in or out if these individuals and/or vehicles you found do reside and/or are garaged in the insured policy address.Request Permission Before Copying 5 . For search results 3 to 4 months prior to policy inception **Caution**: Underwriting should have run their own search prior to writing the insurance policy to avoid AP’s at the stage of a claim.law enforcement jurisdiction who responded to the scene (you may want to call ahead to see how much it will cost to obtain a copy of the police report). a) Why you run this search: This database search is done to see if the information contained in the policy is true and correct. Written by Rhina C.The amount an individual pays when they initially obtain insurance coverage through an insurance carrier is called a “premium”. Insurance carriers input information into this database when an accident occurs. BI (Bodily Injury) or WC (Workers’ Comp) claims filed in the past (look for trends in these search results). Each insurance company has their own search system that they use. (Put in your notes POSSIBLE) You can’t deny the claim based solely on your search. 2nd running a search on the driver’s license attached to the address. Bustamante. Individuals that reside in the household who do not hold a driver’s license generally do not create high amount AP’s. persons. and vehicles that appear in the results 3 to 4 months prior to the policy inception date up to the date you are running the search. the same is said for any vehicles that are garaged at the insured policy address but yet are not listed on the policy. Premium. If a licensed individual resides in the household and is not listed on the policy they create an AP (additional premium) to the policy. Ask your manager or supervisor to provide you a copy of the company’s policy application so you can see what questions insured’s are asked prior to obtaining a policy. 4) Investigation Tool: Run a search on the policy address to see who who resides in the insured policy address and what unlisted vehicles are in the insured policy address: you will start by 1st running a search on the address.
The insured and/or claimant have the right to have their attorney present.Request Permission Before Copying 6 . and/or IME (Independent Medical Examination) appointment. 6) Provider(s): Ensure you always indicate via correspondence the status of the claim with provider(s). Follow the protocol your insurance company has set in place with regard to how they would like you to mail these letters/appointments.Reservation of Rights letter (where insurance company reserves the right to deny all or a partial amount of the claim). IME appointments. EUO appointments. The insured and/or claimants are usually question by the insurance company SIU adjuster or insurance company attorney. When you receive medical bills ensure the provider has submitted a Disclosure and Acknowledgment Form. Bustamante.This is a medical appointment. Inquire with your manager and/or supervisor as to how they would like for you to discuss coverage issues with the provider whether by phone or mail or both. the attorney can be present via telephone or in person. or other medical institution providing medical services upon which a claim for PIP benefits is based shall require an insured person. Some insurance carriers provide coverage information to the provider via telephone and other insurance carriers would like for the provider to inquire coverage information via correspondence (via fax and/or mail). to execute a disclosure and acknowledgment Written by Rhina C. the first set of bills (meaning bills from the first date of service) must be received within 35 days. clinic. Initiation of Treatment (IOT) letter’s must be received in the insurance company’s office before the 21st day from the first date of treatment in order for the provider to have the 75 day open window to which submit bills from the first date of treatment. Florida Statute (5)(e) states “At the initial treatment or service provided. each physician. If during the course of your investigation (early on in the investigation) you should send a claimant to an IME appointment. or his or her guardian. 7) Medical Bills: Cross check the post mark date on the envelope and date stamp that the mail personnel in your insurance company stamped to note when the bills were received.5) Letters Sent to Insured/Claimants: Whether or not you or your assistant mails out the following is based on your investigation: ROR. If there is no IOT of letter received.This is an appointment in which insured and/or claimants are questioned in person under oath in front of a court reporter as to the facts of the accident. status of the claim (whether it is still in the investigation status and/or if coverage has been cleared). Providers will contact you via telephone and/or correspondence to inquire the following: coverage inquiries (they will inquire to ensure there is coverage for the medical bills which they shall be mailing). EUO(Examination under Oath) appointment. and to inquire the status of their medical bills (whether they are going to be paid and /or denied). other licensed professional. ensure you send them to a doctor who holds the same specialty as the doctor they are currently treating with.
80% of all reasonable expenses for medically necessary medical.s. Written by Rhina C. (Make sure you have an original). as defined in s. you are human! If you do come across a claim where there are fatalities follow Florida Statute 627.form…” Florida Statute requires the provider submits the original Disclosure & Acknowledgment Form to the insurance company.Request Permission Before Copying 7 . persons operating the insured motor vehicle. The insurer may pay such benefits to the executor or administrator of the deceased. The amount required to be in reserve may be used only to pay claims from such physicians or dentists until 30 days after the date the insurer receives notice of the accident. and nursing services… Disability Benefits. 395. x-ray. any amount of the reserve for which the insurer has not received notice of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used by the insurer to pay other claims…” 8) Death Benefits: This is the hardest and most difficult part of being a PIP adjuster.002(9). disease. plus all expenses reasonably incurred…All disability benefits payable under this provision shall be paid not less than every 2 weeks…” Death Benefits. services including prosthetic devices. and other persons struck by such motor vehicle and suffering bodily injury while not an occupant of a self-propelled vehicle. relatives residing in the same household. passengers in such motor vehicle. and medically necessary ambulance. If you become emotional it is okay. subject to the provisions of subsection (2) and paragraph (4)(e) to a limit of 10k for loss sustained as a result of bodily injury. to any of the deceased’s relatives by blood or legal adoption or connection by marriage. Bustamante. After the 30-day period.736 (1) “Required Benefits” which states “ Every insurance policy…shall provide PIP to the named insured. or who provide hospital inpatient care. maintenance. surgical. or use of a motor vehicle as follows: Medical Benefits. When automobile accidents occur there is a great chance of there being fatalities. or death arising out of the ownership. or to any person appearing to the insurer to be equitably thereto…” Note: Follow Florida Statute 627. Emergency Services & Care Bills: Follow Florida Statute 627. dental and rehab.736 (4)(c) which states “The insurer must reserve 5k of PIP benefits for payment to physicians licensed under chapter 458 (MD) or chapter 459 (Osteopathic) or dentists licensed under chapter 466 who provide emergency services and care.see #8 for further.60% of any loss of gross income and loss of earning capacity per individual from inability to work proximately caused by the injury sustained by the injured person. sickness. hospital.736 (1)(c) which states “…Death benefits equal to the lesser of the 5k or the remained of unused PIP benefits per individual.
736(10) (c)) As mentioned in Florida Statute 627.736 (4)(d) & Florida Statute 627. The insurance carrier is also responsible for interest.9) Demands: This is the pre-suit stage. The demand letter should follow Florida Statute 627. penalty and postage for bills not paid within the time frame set in place by statute (See Florida Statute 627.736(4)(b)”…PIP benefits shall be overdue if not paid within 30 days after the insurer is furnished with written notice of the fact of a covered loss and of the amount of the same…” As I indicated previously some insurance carriers have Litigation PIP Adjusters handle the claim once it is in this stage Written by Rhina C.726 (10)(c).736(10) (b) and Florida Statute 627. When a provider submits medical bills and they are not paid the provider can submit to the insurance company a demand letter.Request Permission Before Copying 8 . Bustamante. this statute contains the responsibilities for the provider and how they must submit the demand.
EOB= Explanation of Benefits H/H= Household MM= Material Misrepresentation P/R= Police Report LOR= Letter of Representation Florida Statute 627.732 is an excellent statute to print for further definition. Print this statute and place by your desk! Written by Rhina C. the original amount of the bill.Request Permission Before Copying 9 . This log contains information regarding medical bills: this log should specify when (date) bill was paid or denied. bill amount after applied to deductible. bill amount after applied to fee schedule. Bustamante. Each individual will have their own separate PIP log.PIP Adjuster Dictionary: (most commonly used terms and their meaning) Insd= Insured N/I= Named Insured I/V= Insured Vehicle VOP= Vehicle on Policy Clmnt= Claimant O/V= Other Vehicle O/P= Other Party DOL= Date of Loss U/W= Underwriting AP= Additional Premium DNOP= Driver Not Listed on Policy VNOP= Vehicle Not Listed on Policy AOB= Assignment of Benefits D&A= Disclosure and Acknowledgment Form IOT= Initiation of Treatment IME= Independent Medical Examination EUO= Examination Under Oath S/S= Sworn Statement R/S= Reschedule and/or Recorded Statement C/O= Cut-off Attny= Attorney Adj= Adjuster MVR= Motor Vehicle Run (Driving Records) PIP Log= Log that is maintained by the PIP adjuster. bill amount after applied to 80%.
If an individual has COMP automatically know they also have COLL. PD= Property Damage (This coverage covers vehicles or property that the policy holder damages) BI= Bodily Injury (This covers other persons that are injured. Florida Statute 627.Auto Policy Coverage’s: Check with your insurance company’s underwriting department if you have any questions with regard to the policy coverage’s. not those listed in the policy or resident relatives of those listed in the policy) PIP= Personal Injury Protection (This covers injuries to the policy holder.Request Permission Before Copying 10 .736 Important Sections for PIP Adjuster’s: This statute should be printed and placed by your desk! Written by Rhina C. listed drivers and resident relatives of the policy holder) UM= Uninsured Motorists COMP= Comprehensive COLL= Collision COMP/COLL= (This covers damage to the vehicle listed on the policy) Note: COMP/COLL coverage can’t be purchased separately. Bustamante.
736 (4)(c) The insurer must reserve 5k of PIP benefits for payment to physicians licensed under chapter 458 (MD) or chapter 459 (Osteopathic) or dentists licensed under chapter 466 who provide emergency services and care. or who provide hospital inpatient care.Request Permission Before Copying 11 . or declined to pay and any information that the insurer denies the claimant to consider related to the medical necessity of the denied treatment or to explain the reasonableness of the reduced charge.730-627. any insurance fraud relating to PIP coverage under his or her policy. Interest: Fla Statute 627.002(9).s. whichever is greater. Interest shall be due at the time payment of the overdue claim is made. 1st 30 days 5k Reserves: Fla Statute 627. 395.736 (4)(b) When an insurer pays only a portion of a claim or rejects a claim. by a material act or omission. Written by Rhina C. Bustamante. the insurer shall provide at the time of the partial payment or rejection an itemized specification of each item that the insurer had reduced.736 (h) Benefits shall not be due or payable to or on the behalf of an insured person if that person has committed.Reporting of loss: Fla Statute 627. provided that this shall not limit the introduction of evidence at trial.736 (4)(d) All overdue payments shall bear simple interest at the rate established under s. 627. for the year in which the payment became overdue. calculated from the date the insurer was furnished with written notice of the amount of the covered loss. if the fraud is admitted to in a sworn statement by the insured or if it is established in a court of competent jurisdiction. any amount of the reserve for which the insurer has not received notice of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used by the insurer to pay other claims.03 or the rate established in the insurance contract. Any insurance fraud shall void all coverage arising from the claim related to such fraud under the PIP coverage of the insured person who committed the fraud.736 (4)(a) An insurer may require written notice to be given as soon as practicable after an accident involving a motor vehicle with respect to which the policy affords the security required by s.s. and the insurer shall include the name and address of the person to whom the claimant should respond and a claim number to be referenced in future correspondence. as defined in s.s 55.7405 EOB and/or Denial: Fla Statute 627. After the 30-day period. omitted. Insurance Fraud: Fla Statute 627. irrespective of whether a portion of the insured person’s claim may be legitimate and any benefits paid prior to the discovery of the insured person’s insurance fraud shall be recoverable by the insurer from the person who committed insurance fraud in their entirety.
supplies.736 (5) The insurer may limit reimbursement to 80 % of the following schedule of maximum charges: (a). if the provider submits to the insurer a notice of initiation of treatment within 21 days after its examination or treatment of the claimant. 200% of the allowable amount under the participating physicians schedule of Medicare Part B. Box 31: (CMS 1500 Form) Fla Statute 627. the insurer may limit reimbursement to 80% of the maximum reimbursable allowance under workers’ compensation. Written by Rhina C. 395. Including degrees or credentials”.Charges for treatment of injured persons: Fla Statute 627.13 and rules adopted thereunder which are in effect at the time such services. supplies.For all medical services. 200% of Medicare (b). as determined under s. supplies or care is not reimbursable under Medicare Part B. except for past due amounts previously billed on a timely basis under this paragraph.For hospital outpatient services. However.For ER services and care as defined by s. other than ER services and care. other than ER services and care. 440. 21 Day IOT.002 or inpatient services rendered at a hospital-owned facility. supplies.35/75 Submission of claims rules: Fla Statute 627. Service.736 (5)(d) All providers other than hospitals shall include on the applicable claim form the professional license number of the provider in the line. Bustamante. the statement of charges must be furnished to the insurer by the provider and may not include.For ER services and care provided by a hospital licensed under chapter 395.Request Permission Before Copying 12 . 75% of the hospital’s usual and customary charges. the usual and customary charges in the community.For ER transport and txmnt by providers licensed under chapter 401. (d). or care is provided. (c). or space provided for “Signature of Physician or Supplier. (f). and care. or care that is not reimbursable under Medicare or workers’ compensation is not required to be reimbursed by the insurer. 200% of the Medicare part A prospective payment applicable to the specific hospital providing the inpatient services. other than medical services billed by a hospital or other provider for ER services as defined in s.736 (5)(c) With respect to any treatment or service. the statement may include charges for treatment or services rendered up to. and except that. but not more than 75 days before the postmark date of the statement. and the insurer is not required to pay charges for treatment or services rendered more than 35 days before the postmark date or electronic transmission date of the statement.For hospital outpatient services. if such services. 200% of the Medicare part A prospective payment applicable to the specific hospital providing the inpatient services.002(9) provided in a facility licensed under chapter 395 rendered by a physician or dentist. 395. (e). and related hospital inpatient services rendered by a physician or dentist.
up to $500.Disclosure & Acknowledgment Form: Fla Statute (5)(e) At the initial treatment or service provided. or his or her guardian. If the insurer determines that the insured has been improperly billed. If a reduction is made due to such written notification by any person.Request Permission Before Copying 13 . up to $500. the person making the written notification and the provider of its findings and shall reduce the amount of payment to the provider by the amount determined to be improperly billed. or other medical institution rendering services for which payment is being claimed explained the services to the insured or his or her guardian. or his or her guardian. (e)(1)(e) If the insured notifies the insurer in writing of a billing error.00. clinic or other medical institution rendering services for which payment is being claimed has the affirmative duty to explain the services rendered to the insured. to execute a disclosure and acknowledgment form. an insurer shall investigate any claim of improper billing by a physician or other medical provider. (e)(1)(d) The physician. or other medical institution providing medical services upon which a claim for PIP benefits is based shall require an insured person. or his or her guardian. The insurer shall determine if the insured was properly billed for only those services and treatments that the insured actually received. or his or her guardian. If the provider is arrested due to the improper billing. other licensed professional. (e)(1)(c) The insured. the insured may be entitled to a certain percentage of a reduction in the amounts paid by the insured’s motor vehicle insurer. or his or her guardian. each physician. other licensed professional. (e)(1)(b) The insured. clinic. Fla Statute (5) (e) (5) The original disclosure and acknowledgment form shall be furnished to the insurer pursuant to paragraph (4) (b) and may not be electronically furnished. or his or her guardian. Bustamante. Informed Consent: Fla Statute (5)(e)(2) The physician. then the insurer shall pay to the person 40% of the amount of the reduction. Loss Wage Form: Written by Rhina C. the insurer shall notify the insured. must countersign the form attesting to the fact that the services set forth therein were actually rendered. has both the right and affirmative duty to confirm that the services rendered were actually rendered. the insurer shall pay to the person 20% of the amount of the reduction. which reflects at a minimum that: (e)(1)(a) The insured. other licensed professional. clinic. Improper Billing: Fla Statute (5) (f) Upon written notification by any person. so that the insured. countersigns the form with informed consent. was not solicited by any person to seek any services from the medical provider.
Fla Statute (6)(a) Each employer shall. a party causing an examination to be made shall deliver to him or her a copy of every written report concerning the examination rendered by an examining physician. of the person upon whose injury the claim is based. IME Appointments: Fla Statute (7)(b) If requested by the person examined. if a request is made by an insurer provider PIP benefits under ss. 3. The name of the insured upon which benefits are being sought. foreign or alien shall file with the office designation of the name and address of the person to whom notices pursuant to this subsection shall be sent which the office shall make available on its Internet website. in a form approved by the office. or may thereafter examine him or her in respect to the same mental or physical condition. The claim number or policy number upon which such claim was originally submitted to the insurer. the party causing the examination to be made is entitled.Request Permission Before Copying 14 . upon request to receive from the person examined every written report available to him or her or his or her representative concerning any examination. 2. the name of any medical provider who rendered to an insured the treatment. Each licensed insurer whether.730-627. previously or thereafter made. and the type of benefit claimed to be due. of the same mental or physical condition. at least one of which reports must set out the examining physicians’ findings and conclusions in detail. or by taking the deposition of the examiner. services.736(10) (c) Each notice required by this section must be delivered to the insurer by USPS certified or registered mail. in relation to the claim for benefits. a sworn statement of the earnings. including a copy of the assignment giving rights to the claimant if the claimant is not the insured. when the insurer pays the claims. Such postal costs shall be made reimbursed by the insurer if so requested by the claimant in the notice. Mailing requirement for Demands: Fla Statute 627. since the time of the bodily injury and for a reasonable period before the injury. By requesting and obtaining a report of the examination so ordered. or accommodation. regarding the testimony of every other person who has examined. return receipt requested. Demands: Fla Statute 627. furnish forthwith. or supplies that form the basis of such claim. service. Bustamante. domestic. After such request and delivery.736(10) (b) The notice required shall state that it is a “demand letter under s 627. the PIP carrier is no longer liable for subsequent PIP benefits. To the extent applicable. If a person unreasonably refuses to submit to an examination. the person examined waives any privilege her or she may have.736(10)” and shall state with specificity: 1. 627. the date of treatment. Written by Rhina C.7405 against whom a claim has been made. and an itemized statement specifying each exact amount. accommodations.
Medical. within the 30 days after the receipt of notice by the insurer.736(10)(f) Any insurer making a general business practice of not paying valid claims until receipt of the notice required by this subsection is engaging in an unfair trade practice under the insurance code. and rehab services including prosthetic devices. or use of a motor vehicle. Any part or all of the remainder of the claim that is subsequently supported by written notice is overdue if not paid within 30 days after such written notice is furnished. 3. any partial amount supported by written notice is overdue if not paid within 30 days after such written notice is furnished to the insurer.736(10) (d) If. maintenance. child. except that benefits received under workers’ compensation law shall be credited against the benefits provided by subsection (1) and shall be due and payable as loss accrues. x-ray. Bustamante. An entity wholly owned by one or more physicians licensed under 458 (MD). An entity wholly owned directly or indirectly by a hospital or hospitals. 2.736(4) Benefits due from an insurer under 627. subject to a maximum penalty of $250. If such written notice is not furnished to the insurer as to the entire claim.80% of all reasonable expenses for medically necessary surgical. When AHCA provides. 459 (Osteopathic) or a Chiro under 460. hospital and nursing services. A person or entity licensed under 401-2101-401-45.730-627. the overdue claim specified in the notice is paid by the insurer together with applicable interest and a penalty of 10% of the overdue amount paid by the insurer. disease. or becomes liable for medical assistance under Medicaid related to injury. A hospital or ambulatory surgical center licensed under 395.Request Permission Before Copying 15 .730-627. Written by Rhina C. PIP benefits shall be overdue if not paid within 30 days after the insurer is furnished written notice of the fact of a covered loss and of the amount of the same. sickness. upon receipt of reasonable proof of such loss and the amount of expenses and loss incurred which are covered by the policy. A health care clinic licensed under 400. or death arising out of the ownership. supervised or prescribed by a physician licensed under chapter 458(MD). The medical benefits shall provide reimbursement only for such services and care that are lawfully provided. Insurers Not Paying Valid Claims: Fla Statute 627.990-400. 4.7405 shall be primary. a dentist licensed under 466 or a Chiro licensed under 460 or are provided by any of the following: 1. pays. Benefits: Fla Statute 627.Penalty Payments with regard to Demands: Fla Statute 627. no action may be brought against the insurer. dental. benefits under 627. 5. and medically necessary ambulance.995 that is. or sibling of that practitioner or those practitioners. 459 (Osteopathic).7405 shall be subject to the provisions of the Medicaid program. or a dentist licensed under 466 or by such practitioner or practitioners and the spouse.
Bustamante. BILLING (CMS 1500): (Providers form to submit services rendered) Box 1: An X should be placed where “other” is indicated. The insurer may pay such benefits to the executor or administrator of the deceased. to any of the deceased’s relatives by blood or legal adoption or connection by marriage. 459 (Osteopathic) or 460 (Chiropractic). Written by Rhina C.60% of any loss wages or gross income and loss of earning capacity per individual from inability to work proximately caused by the injury sustained by the injured person. Reference: § 627. All disability benefits payable under this provision shall be paid not less than every 2 weeks. Has been continuously licensed for more than 3 years or is a publicly traded corp that issues securities traded on an exchange registered with the US Securities & Exchange Commission. (2010).Box 8 should indicate the patient (who can also be the insured’s) demographic information.736. **Box 2.Request Permission Before Copying 16 . Note: If the insured is other than the patient such as a spouse or child this is a good place to check relationship status.a. the Commission on Accreditation of Rehab Facilities or the Accreditation for Ambulatory Health Care or a healthcare clinic that: b. Physical therapy f. General medicine b. c. Fla. Stat. Fla. or to any person appearing to the insurer to be equitably thereto.732. Death Benefits. Ortho medicine d. Laboratory services Disability Benefits. Stat. Accredited by the JCAHO. Physical medicine e.Death benefits equal to the lesser of the 5k or the remained of unused PIP benefits per individual. plus all expenses reasonably incurred in obtaining from others ordinary and necessary services in lieu of those that but for the injury the injured person would have performed without income for the benefit of his or her household. (2010) & § 627. the American Osteo Association. Radiography c. Has a medical director licensed under 458 (MD). Provides at least four of the following medical specialties: a. Prescribing or dispensing outpatient prescription medication g.
cms. Bustamante.This box indicates the patients account number for provider that is billing. Stat.732. Box 26. charge amount and services rendered to the patient while in the facility.This box should indicate the dates.736. Box 22-23.asp?filterType=none&filterByDID=99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10 REFERENCE PAGE Florida Statute § 627.20. (2010). **Box 24. (Reason patient is seeking treatment). (Normally there is no signature but rather it will state “Signature on File”) Box 13.Box 9-11d will indicate the Insurance Company’s information inclusive of a claim or police number. Services rendered will be indicated by CPT Codes.This box should indicate the name of the referring physician.leg. **Box 21. **Box 27.Request Permission Before Copying 17 . **Box 25.This box indicates amount that has been paid to provider if any. (Meaning the name of the MD/DC/DO who referred the patient to this facility.the facility that is using the form to bill the insurance carrier) If left blank.This box indicates the total amount charged (what is to be paid to provider). (2010) § 627.This should state the date when the accident/incident occurred. Department of Health & Human Services. Box 15-17. Box 30.Are usually left blank.fl.state.Insured’s signature.Are usually left blank. (Normally there is no signature but rather it will state “Signature on File”) Box 14. Retrieved via internet May 2011: http://www. Box 12.This box is one that has been constantly debated in courts between providers attorney’s and insurance carrier’s attorney.Nature of illness or injury will be indicated by ICD Codes.Name and address where services were rendered to patient.This box should indicate if the provider is accepting an assignment of benefits. Fla. **Box 17. Stat. Box 29.the provider is indication the patient was not referred to them. **Box 31. (Provider’s demographic) **Box 33-Physician’s demographics.Patient’s signature.CMS 1500 Form Written by Rhina C. (Meaning benefits will be paid directly to the provider) Box 28.This box should indicate the nature of the illness or injury.Are usually left blank.Provider’s federal tax ID number. (Refer to Fla Statute 627. Fla. Box 18. (Normally repeats information contained in box 32) ** Important Sections** This form can be found at Centers for Medicare & Medicaid Services website: http://www.us/Statutes/ U. Centers for Medicare and Medicaid Services.S.This box indicates the total amount due to provider.736 (5) (d)) **Box 32.gov/CMSForms/CMSForms/itemdetail.
gov/CMSForms/CMSForms/itemdetail.Retrieved via internet May 2011: http://www. Bustamante.cms.Request Permission Before Copying 18 .asp? filterType=none&filterByDID=99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10 Written by Rhina C.
This action might not be possible to undo. Are you sure you want to continue?