Chapter 69L-3 Workers’ Compensation Claims
Chapter 69L-4 Assessments
Chapter 69L-5 Rules for Self-Insurers Under the Workers’ Compensation Act
Chapter 69L-6 Workers’ Compensation Compliance
Chapter 69L-7 Workers’ Compensation Medical Reimbursement and Utilization Review
Chapter 69L-8 Selected Materials Incorporated by Reference
Chapter 69L-10 Claim for Reimbursement Against the Special Disability Trust Fund
Chapter 69L-22 Reemployment Services – Workers’ Compensation
Chapter 69L-24 Insurers’ Standards and Practices
Chapter 69L-26 Employee Assistance and Ombudsman Office
Chapter 69L-30 Expert Medical Advisors
Chapter 69L-31 Utilization and Reimbursement Dispute Rules
Chapter 69L-34 Carrier Report of Health Care Provider Violations
Chapter 69L-56 Electronic Data Interchange (Edi) Requirements for Proof of Coverage and Claims (Non-Medical)

Terms Used In Florida Regulations > Division 69L

  • Accurately Completed: means the form submitted contains the information necessary to meet the requirements of chapter 440, F. See Florida Regulations 69L-7.710
  • acknowledgement: means a response provided by the Division to communicate the acceptance or rejection of an electronic transaction sent to the Division. See Florida Regulations 69L-56.002
  • Adjusted: means payment is made with modification to the information provided on the bill. See Florida Regulations 69L-7.710
  • Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
  • Allegation: something that someone says happened.
  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
  • Appellate: About appeals; an appellate court has the power to review the judgement of another lower court or tribunal.
  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
  • Average Wage: means the employee's average weekly wage as determined in section 440. See Florida Regulations 69L-56.002
  • Batch: means a set of records containing one header record, one or more detailed transactions, and one trailer record. See Florida Regulations 69L-56.002
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Billing: means the process by which a health care provider submits a medical claim form or medical bill to an insurer, claim administrator or any entity acting on behalf of the insurer, to receive reimbursement for medical services, goods or supplies provided to an injured employee. See Florida Regulations 69L-7.710
  • Biweekly work week: means two consecutive 7-day periods coinciding with the post injury employer's work week. See Florida Regulations 69L-3.002
  • Business day: means a day on which normal business is conducted by the State of Florida and excludes observed holidays as set out in Florida Statutes § 110. See Florida Regulations 69L-56.002
  • Calculated Weekly Compensation Amount: means 66 2/3 % of the employee's average weekly wage pursuant to section 440. See Florida Regulations 69L-56.002
  • Catastrophic Event: means the occurrence of an event outside the control of a claim administrator or any entity acting on behalf of the insurer, such as an electronic data transmission failure due to a natural disaster or an act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent a claim administrator or any entity acting on behalf of the insurer from meeting the filing and reporting requirements of chapter 440, F. See Florida Regulations 69L-7.710
  • Catastrophic Event: means the occurrence of an event outside the control of an insurer, claim administrator, or third party vendor, such as a telecommunications failure due to a natural disaster or act of terrorism (including but not limited to cyber terrorism), in which recovery time will prevent an insurer, claim administrator, or third party vendor from meeting the filing requirements of chapter 440, F. See Florida Regulations 69L-56.002
  • Charge Master: means for hospitals a comprehensive listing of all the goods and services for which the facility maintains a separate charge, with the facility's charge for each of the goods and services, regardless of payer type and means; for ASCs a listing of the gross charge for each CPT procedure for which an ASC maintains a separate charge, with the ASC's charge for each CPT procedure, regardless of payer type. See Florida Regulations 69L-7.710
  • Charges: means the dollar amount billed. See Florida Regulations 69L-7.710
  • Claim Administrator: means any insurer, claims-handling entity, qualified servicing entity, service company/third-party administrator (Service Co/TPA), self-serviced self-insured employer or fund, or managing general agent and includes all claims office locations that will be responsible for adjusting and submitting workers' compensation claims to the Division. See Florida Regulations 69L-3.002
  • Claim Administrator: means any insurer, qualified servicing entity, third party administrator, claims-handling entity, self-serviced self-insured employer or fund, guarantee fund, or managing general agent responsible for adjusting workers' compensation claims. See Florida Regulations 69L-7.710
  • Claim Administrator: means any insurer, service company/third party administrator, self-serviced self-insured employer or fund, or managing general agent, responsible for adjusting workers' compensation claims, that is electronically sending its data directly to the Division. See Florida Regulations 69L-56.002
  • Claim Type Code: means a code representing the current classification of the claim as either a "Lost Time/Indemnity Case" (Claim Type Code "I"), "Medical Only to Lost Time Case" (Claim Type Code "L"), "Became Medical Only Case" (Claim Type Code "B") or "Medical Only Case" (Claim Type Code "M"). See Florida Regulations 69L-56.002
  • Client Company: is a s defined in section 468. See Florida Regulations 69L-56.002
  • Compensation Rate: means 66 2/3% of the employee's average weekly wage pursuant to section 440. See Florida Regulations 69L-3.002
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Continuance: Putting off of a hearing ot trial until a later time.
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Days: means calendar days unless otherwise noted. See Florida Regulations 69L-3.002
  • Days: means calendar days unless otherwise noted. See Florida Regulations 69L-7.710
  • Days: means calendar days, unless otherwise noted. See Florida Regulations 69L-56.002
  • Denied: means payment is not made because the service rendered is for treatment of a non-compensable injury or illness. See Florida Regulations 69L-7.710
  • Denied Case: means a "Full Denial" or "Partial Denial" case for which all indemnity benefits are initially denied by the claim administrator. See Florida Regulations 69L-56.002
  • Department: means Department of Financial Services (DFS) as defined in subsection 440. See Florida Regulations 69L-7.710
  • Dependent: A person dependent for support upon another.
  • Deposition: An oral statement made before an officer authorized by law to administer oaths. Such statements are often taken to examine potential witnesses, to obtain discovery, or to be used later in trial.
  • Disallowed: means payment for a compensable injury or illness is not made because the service rendered has not been substantiated for reasons of medical necessity, insufficient documentation, lack of authorization or billing error. See Florida Regulations 69L-7.710
  • Dismissal: The dropping of a case by the judge without further consideration or hearing. Source:
  • Division: means the Division of Workers' Compensation (DWC) as defined in subsection 440. See Florida Regulations 69L-7.710
  • Division: means the Division of Workers' Compensation. See Florida Regulations 69L-56.002
  • Document: means any notice, form, or report which shall be submitted to the Division under this chapter or which the Division requests in connection with any matter covered by this chapter. See Florida Regulations 69L-3.002
  • Electronic Form Equivalent: means the record, provided in the Florida Medical EDI Implementation Guide MEIG to be used when a sender electronically transmits required data to the Division. See Florida Regulations 69L-7.710
  • Electronic Form Equivalent: means information sent in Division-approved electronic formats as specified in this rule, instead of otherwise required paper documents. See Florida Regulations 69L-56.002
  • Electronic funds transfer: The transfer of money between accounts by consumer electronic systems-such as automated teller machines (ATMs) and electronic payment of bills-rather than by check or cash. (Wire transfers, checks, drafts, and paper instruments do not fall into this category.) Source: OCC
  • Employee Leasing: is a s defined in section 468. See Florida Regulations 69L-56.002
  • Employee Leasing Company: is a s defined in section 468. See Florida Regulations 69L-56.002
  • Employee Leasing Policy Identification Code: is a code which identifies a policy written as an employee leasing policy, and the type of leasing operation. See Florida Regulations 69L-56.002
  • Employer Paid Salary in Lieu of Compensation: means the employer paid the employee salary, wages, or other remuneration for a period of disability for which the insurer would have otherwise been obligated to pay indemnity benefits. See Florida Regulations 69L-56.002
  • Entitlement: A Federal program or provision of law that requires payments to any person or unit of government that meets the eligibility criteria established by law. Entitlements constitute a binding obligation on the part of the Federal Government, and eligible recipients have legal recourse if the obligation is not fulfilled. Social Security and veterans' compensation and pensions are examples of entitlement programs.
  • Entity: means any party involved in the processing, adjudication or payment of medical bills on behalf of the insurer. See Florida Regulations 69L-7.710
  • 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.
  • Felony: A crime carrying a penalty of more than a year in prison.
  • Filed: means a document has been received and accepted in accordance with rule 69L-3. See Florida Regulations 69L-3.002
  • Filed: means a transaction has been received by the Division and passes quality and structural edits and is assigned an Application Acknowledgement Code of "TA" (Transaction Accepted). See Florida Regulations 69L-56.002
  • Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
  • Fraud: Intentional deception resulting in injury to another.
  • FROI: means the First Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and is comprised of the First Report of Injury Record identified by Transaction Set ID "148" paired with the First Report of Injury Companion Record identified by Transaction Set ID "R21. See Florida Regulations 69L-56.002
  • Full Denial: means any case for which the claim administrator has denied liability for all workers' compensation benefits (i. See Florida Regulations 69L-56.002
  • Gross Weekly Amount: means the weekly amount payable for a specific Benefit Type and excludes the application of any Benefit Adjustments or Benefit Credits. See Florida Regulations 69L-56.002
  • Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
  • Header Record: means the first record of a batch. See Florida Regulations 69L-56.002
  • IAIABC: means the International Association of Industrial Accident Boards and Commissions (www. See Florida Regulations 69L-56.002
  • Implants: means the Surgical Implant(s), the Associated Disposable Instrumentation required for use with the Surgical Implant(s), and shipping and handling, when listed on the implant invoice or certified on the DFS-F5-DWC-90 claim form. See Florida Regulations 69L-7.710
  • Industry Code: means the 5 or 6-digit code that represents the nature of the employer's business as published in the North American Industry Classification System (NAICS) 2007 Edition, hereby incorporated by reference. See Florida Regulations 69L-56.002
  • Initial Date of Lost Time: means the employee's eighth (8th) day of disability, i. See Florida Regulations 69L-56.002
  • Initial Disposition: means the first action taken by the claim administrator following its knowledge of an injury to accept or deny compensability of the claim and pay or deny benefits, including payment or denial of both indemnity and medical benefits, or denial of indemnity benefits only. See Florida Regulations 69L-56.002
  • Insurer: means an insurer as defined in section 440. See Florida Regulations 69L-56.002
  • Insurer Code Number: means the number the Division assigns to each individual insurer, self-insured employer, self-insured fund, or guaranty fund financially responsible for the claim. See Florida Regulations 69L-7.710
  • Itemized Statement: means a detailed listing of goods, services and supplies provided to an injured employee, including the quantity and charges for each good, service or supply. See Florida Regulations 69L-7.710
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Knowledge: means an entity's earliest receipt of information, including mail, telephone, facsimile, direct personal contact or electronic submission. See Florida Regulations 69L-3.002
  • Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
  • Liabilities: The aggregate of all debts and other legal obligations of a particular person or legal entity.
  • Lien: A claim against real or personal property in satisfaction of a debt.
  • Lost Time Case: means a work-related injury or illness, which has caused the employee to be disabled for more than 7 calendar days or for which indemnity benefits have been paid. See Florida Regulations 69L-3.002
  • Manual Classification Code: means the 4-digit code assigned by the National Council on Compensation Insurance (NCCI) for the particular occupation of the injured employee as documented in the NCCI Scopesâ„¢ Manual 2009 Edition, which is hereby incorporated by reference. See Florida Regulations 69L-56.002
  • Medical Bill: means the document or electronic form equivalent submitted by a health care provider to an Insurer, Service Company/Third Party Administrator or any entity acting on behalf of the Insurer for reimbursement for services or supplies (e. See Florida Regulations 69L-7.710
  • Medical Only Case: means a work-related injury or illness which requires medical treatment for which charges will be incurred, but which does not cause the employee to be disabled for more than 7 calendar days. See Florida Regulations 69L-56.002
  • Misdemeanor: Usually a petty offense, a less serious crime than a felony, punishable by less than a year of confinement.
  • NDC Number: means the eleven-digit National Drug Code (NDC) number, assigned under Section 510 of the Federal Food, Drug, and Cosmetic Act, which identifies the drug product labeler/vendor, product, and trade package size. See Florida Regulations 69L-7.710
  • Net Weekly Amount: means the weekly amount paid for an indemnity benefit such as temporary total benefits, impairment income benefits, etc. See Florida Regulations 69L-56.002
  • Nolo contendere: No contest-has the same effect as a plea of guilty, as far as the criminal sentence is concerned, but may not be considered as an admission of guilt for any other purpose.
  • Notification: means an entity's earliest receipt of information, including by mail, telephone, facsimile, direct personal contact, or electronic submission. See Florida Regulations 69L-56.002
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Paid: means payment is made applying the applicable reimbursement formula to the medical bill as submitted. See Florida Regulations 69L-7.710
  • Partial Denial: means a case where compensability is accepted but the claim administrator initially denies all indemnity benefits and only medical benefits will be paid; Partial Denial also means a case where a specific indemnity benefit(s) was previously paid but subsequently denied, either in whole or in part. See Florida Regulations 69L-56.002
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • Permanent Impairment Percentage: means "Permanent Impairment" as defined in section 440. See Florida Regulations 69L-56.002
  • Plea: In a criminal case, the defendant's statement pleading "guilty" or "not guilty" in answer to the charges, a declaration made in open court.
  • Probable cause: A reasonable ground for belief that the offender violated a specific law.
  • Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
  • Quorum: The number of legislators that must be present to do business.
  • Recognized Practitioner: means a non-physician health care provider licensed by the Department of Health who works under the protocol of a physician or who, upon referral from a physician, can render direct billable services that are within the scope of the recognized practitioner's license, independent of the supervision of a Physician. See Florida Regulations 69L-7.710
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
  • Report: means any form related to medical services rendered, in relation to a workers' compensation injury that is required to be filed with the Division under rule chapter 69L-7, F. See Florida Regulations 69L-7.710
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
  • Send: means to transmit a document to the party or parties intended to receive it, including by mail, hand delivery, or electronic transmission. See Florida Regulations 69L-3.002
  • Sender: means an Insurer, Service Company/TPA, entity or any other party acting on behalf of an Insurer, Service Company/TPA or any entity to fulfill any Insurer responsibility to electronically transmit required medical data to the Division. See Florida Regulations 69L-7.710
  • Sender: means one of the following entities sending electronic filings to the Division:     (a) Claim Administrator;     (b) Insurer; or     (c) Third Party Vendor (Proof of Coverage only). See Florida Regulations 69L-56.002
  • Service of process: The service of writs or summonses to the appropriate party.
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • SROI: means the Subsequent Report of Injury Record Layout adopted by the IAIABC as a Claims EDI Release 3 standard, and includes the Subsequent Report Record identified by Transaction Set "A49" paired with the Subsequent Report Companion Record identified with Transaction Set ID "R22. See Florida Regulations 69L-56.002
  • Statute: A law passed by a legislature.
  • Statute of limitations: A law that sets the time within which parties must take action to enforce their rights.
  • Subpoena: A command to a witness to appear and give testimony.
  • Testimony: Evidence presented orally by witnesses during trials or before grand juries.
  • Third Party Vendor: means an entity acting as a submission agent or vendor on behalf of an insurer, service company or third party administrator, which has been authorized to electronically send required data to the Division. See Florida Regulations 69L-56.002
  • Trading Partner: means an entity approved by the Division in accordance with rules 69L-56. See Florida Regulations 69L-56.002
  • Trailer Record: means the last record that designates the end of a batch of transactions. See Florida Regulations 69L-56.002
  • Transmission: consists of one or more batches sent to or received by the Division or a trading partner. See Florida Regulations 69L-56.002
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • Triplicate Code: is a series of three two-digit numeric codes that define the specific purpose of individual records in a Proof of Coverage transmission, i. See Florida Regulations 69L-56.002
  • Trustee: A person or institution holding and administering property in trust.