Florida Regulations 69L-24.004: Monitoring, Examining and Investigating
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(1) The Department shall monitor, examine, or investigate the performance of regulated entities to ensure compliance with Florida Statutes Chapter 440 and Department Rules as often as is deemed necessary.
(a) Monitoring includes, but is not limited to, the ongoing review of data provided to the Department by regulated entities.
(b) Examining or investigating includes, but is not limited to, the review of a regulated entity’s processes and shall be based upon:
1. The regulated entity’s performance in prior examinations and/or investigations; or
2. Information obtained through the monitoring process.
(2) Monitoring, examining, or investigating includes, but is not limited to, the review of the following:
(a) Timeliness and accuracy of indemnity and/or medical payments;
(b) Timeliness and accuracy of the filing of medical bill data;
(c) Timeliness and accuracy of all forms required to be reported pursuant to Rules 69L-3.001 through 69L-3.025, F.A.C.;
(d) Timeliness and accuracy of electronic transactions required by Rules 69L-56.001 through 69L-56.500, F.A.C.;
(e) Denial of claims;
(f) Delay in provision of benefits;
(g) Harassment, coercion or intimidation of any party;
(h) Evidence of the mailing and wording of the fraud statement pursuant to Florida Statutes § 440.105(7);
(i) Timeliness of the response to a Petition for Benefits;
(j) Timeliness of the compliance with a Judge of Compensation Claim’s order;
(k) Timeliness of the compliance with a Department rule or order;
(l) Compliance with CPS batch timeframes;
(m) Claims-handling practices;
(n) Timeliness of medical authorizations, which includes authorizations submitted on Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), incorporated in Fl. Admin. Code R. 69L-7.720(1)(d);
(o) Mailing of Form DFS-F2-DWC-65 (Important Workers’ Compensation Information for Florida’s Employers), or Form DFS-F2-DWC-66 (Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida), as incorporated in Fl. Admin. Code R. 69L-3.025, to the employer;
(p) The date that Form DFS-F2-DWC-60 or DFS-F2-DWC-61 (Important Workers’ Compensation Information for Florida’s Workers’ brochure or Informacion Importante De Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida), as incorporated in Fl. Admin. Code R. 69L-3.025, was mailed to the injured worker; and,
(q) Mailing of the Employee Notification Letter, as incorporated in subsection 69L-26.004(6), F.A.C., to the injured worker.
(3) Reports resulting from an examination or investigation conducted under Florida Statutes Chapter 440 and Department Rules, are confidential and exempt from Florida Statutes § 119.07(1), pursuant to Florida Statutes § 624.319, until the examination or investigation ceases to be active.
Rulemaking Authority 440.13(11), 440.185(9), (10), 440.20(6), 440.525(4), 440.591, 440.593(5) FS. Law Implemented 440.13(11), 440.185, 440.20(6),(8), 440.525, 440.593(5) FS. History-New 1-12-10.
Terms Used In Florida Regulations 69L-24.004
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fraud: Intentional deception resulting in injury to another.
(b) Examining or investigating includes, but is not limited to, the review of a regulated entity’s processes and shall be based upon:
1. The regulated entity’s performance in prior examinations and/or investigations; or
2. Information obtained through the monitoring process.
(2) Monitoring, examining, or investigating includes, but is not limited to, the review of the following:
(a) Timeliness and accuracy of indemnity and/or medical payments;
(b) Timeliness and accuracy of the filing of medical bill data;
(c) Timeliness and accuracy of all forms required to be reported pursuant to Rules 69L-3.001 through 69L-3.025, F.A.C.;
(d) Timeliness and accuracy of electronic transactions required by Rules 69L-56.001 through 69L-56.500, F.A.C.;
(e) Denial of claims;
(f) Delay in provision of benefits;
(g) Harassment, coercion or intimidation of any party;
(h) Evidence of the mailing and wording of the fraud statement pursuant to Florida Statutes § 440.105(7);
(i) Timeliness of the response to a Petition for Benefits;
(j) Timeliness of the compliance with a Judge of Compensation Claim’s order;
(k) Timeliness of the compliance with a Department rule or order;
(l) Compliance with CPS batch timeframes;
(m) Claims-handling practices;
(n) Timeliness of medical authorizations, which includes authorizations submitted on Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), incorporated in Fl. Admin. Code R. 69L-7.720(1)(d);
(o) Mailing of Form DFS-F2-DWC-65 (Important Workers’ Compensation Information for Florida’s Employers), or Form DFS-F2-DWC-66 (Informacion Importante Del Seguro De Indemnizacion Por Accidentes De Trabajo Para Los Empleadores De La Florida), as incorporated in Fl. Admin. Code R. 69L-3.025, to the employer;
(p) The date that Form DFS-F2-DWC-60 or DFS-F2-DWC-61 (Important Workers’ Compensation Information for Florida’s Workers’ brochure or Informacion Importante De Seguro De Indeminzacion Por Accidentes De Trabajo Para Los Trabajadores De La Florida), as incorporated in Fl. Admin. Code R. 69L-3.025, was mailed to the injured worker; and,
(q) Mailing of the Employee Notification Letter, as incorporated in subsection 69L-26.004(6), F.A.C., to the injured worker.
(3) Reports resulting from an examination or investigation conducted under Florida Statutes Chapter 440 and Department Rules, are confidential and exempt from Florida Statutes § 119.07(1), pursuant to Florida Statutes § 624.319, until the examination or investigation ceases to be active.
Rulemaking Authority 440.13(11), 440.185(9), (10), 440.20(6), 440.525(4), 440.591, 440.593(5) FS. Law Implemented 440.13(11), 440.185, 440.20(6),(8), 440.525, 440.593(5) FS. History-New 1-12-10.