Free DFS Form 3160-0024 - Florida

Florida Department of Financial Services Division of Workers' Compensation, Office of Medical Services CARRIER RESPONSE TO PETITION FOR RESOLUTION OF REIMBURSEMENT DISPUTE
The Carrier Response to Petition for Resolution of Reimbursement Dispute must be filed with the Agency pursuant to 69L-31.009, Florida Administrative Code. CARRIER NAME: ________________________________________________________________________________________ [MUST BE "carrier" as defined in s.440.13(1)(c), Florida Statutes] CARRIER MAILING ADDRESS: _____________________________________________________________________________ _____________________________________________________________________________ If Carrier Response is submitted by an entity acting on behalf of the Carrier, please provide: ENTITY NAME: __________________________________________________________________________________________ ENTITY MAILING ADDRESS: ______________________________________________________________________________ ______________________________________________________________________________ PETITIONER NAME: ______________________________________________________________________________________ Name of Injured Employee service(s) provided to: _____________________________________________________________ Date(s) of Service Applicable to Petition: ____________________________________________________________________ 1. Provide the name, mailing address and proof of delivery, to the Petitioner, (e.g. delivery confirmation) for the copy of the Carrier Response to Petition for Resolution of Reimbursement Dispute form and all accompanying information served on the Department in response to the Petition. Petitioner Name: ____________________________________________________________________________________ Petitioner Mailing Address: __________________________________________________________________________ Proof of Delivery: ___________________________________________________________________________________ 2. Does the Carrier agree or disagree that the issue(s) identified by the Petitioner in its response to question number 3 on the Petition for Resolution of Reimbursement Dispute form the basis for this reimbursement dispute? __________ If the Carrier disagrees with the Petitioner's response to question 3 on the Petition, please identify all issues the Carrier contends form the basis for this dispute. __________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 3. Please provide a detailed breakdown of the calculations made by the Carrier in arriving at the actual dollar amount reimbursed by the Carrier for the payment that is in dispute. ___________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 4. Does the Carrier agree or disagree with the Petitioner's response to question number 5 of the Petition for Resolution of Reimbursement Dispute? __________ If the Carrier disagrees, please provide a detailed explanation of the nature of the Carrier's disagreement with Petitioner's response. Attach any reimbursement contract provisions relevant to Carrier's response to this question. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________

If additional space is needed to complete your responses to any of the questions, continue on a separate sheet and attach to the form.
DFS Form 3160-0024 (effective 09/08/2006 - for use on or after 11/28/2006) Page 1

Florida Department of Financial Services Division of Workers' Compensation, Office of Medical Services

CARRIER RESPONSE TO PETITION FOR RESOLUTION OF REIMBURSEMENT DISPUTE - Page 2
5. Does the Carrier contend that there are additional grounds for adjustment or disallowance of payment that were not identified on the Explanation of Bill Review? __________ If yes; ___________________________________

(a) Identify the specific additional grounds for adjustment or disallowance.

_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ (b) Explain why the additional grounds for adjustment or disallowance were not identified on the Explanation of Bill Review. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ (c) Identify any peer review consultant(s) or independent medical evaluator(s) involved in identifying the additional grounds for adjustment or disallowance .________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 6. Were any of the documents or records the Carrier is submitting in response to the Petition for Resolution of Reimbursement Dispute created or originated subsequent to the issuance of the Explanation of Bill Review? __________ If yes; (a) Specifically identify the document(s) or record(s) created subsequent to the issuance of the EOBR. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ (b) Explain in detail why the document(s) or record(s) were created or originated subsequent to issuance of the Explanation of Bill Review. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 7. Does the Carrier agree or disagree with the Petitioner's response to question 6 on the Petition for Resolution of Reimbursement Dispute? __________ If the Carrier disagrees, please explain in detail why the Carrier disagrees with Petitioner's response. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Signature of Carrier representative or other representative authorized to respond on behalf of Carrier:

___________________________________________________________
Signature

___________________
Date

Please mail the completed Carrier Response to Reimbursement Dispute to: Division of Workers' Compensation, Office of Medical Services c/o Department of Financial Services 200 East Gaines Street Tallahassee, Florida 32399-4232
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DFS Form 3160-0024 (effective 09/08/2006 - for use on or after 11/28/2006)