Dfs Form 3160-0023 Petition For Resolution Of Reimbursement Dispute
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2Florida Department of Financial Services
Division of Workers' Compensation, Office of Medical Services
PETITION FOR RESOLUTION OF REIMBURSEMENT DISPUTE
A Petition for Resolution of Reimbursement Dispute must be served on the Agency within 30 days after the Petitioner's
receipt of a notice of disallowance or adjustment of payment, pursuant to 69L-31.008, Florida Administrative Code.
PETITIONER NAME: ____________________________________________________________________________________
[MUST BE "Healthcare Provider" as defined in s.440.13(1)(h), Florida Statutes]
PETITIONER MAILING ADDRESS: __________________________________________________________________________
____________________________________________________________________________
If the Petition is submitted by an entity acting on behalf of the Petitioner, please provide:
ENTITY NAME: __________________________________________________________________________________________
ENTITY MAILING ADDRESS: _______________________________________________________________________________
______________________________________________________________________________
Name of Injured Employee service(s) provided to: ____________________________________________________________
Date(s) of Service Applicable to Petition: ____________________________________________________________________
1.
Date of receipt of the Explanation of Bill Review (EOBR) from Carrier. ________________
Select the method Petitioner has used to establish the EOBR date of receipt:
Date Stamp (a date stamped EOBR will be accepted as proof of date of receipt by date stamp).
Verifiable Login Process (a copy of the applicable portion of the login roster showing the date of login of the EOBR will be
accepted as proof of receipt through a verifiable login process).
Postmark Date (a copy of the envelope in which the EOBR was sent which clearly and legibly shows the postmark
date must accompany the petition).
If the Petitioner does not establish the date of its receipt of the Explanation of Bill Review by any of the methods set forth in
this paragraph, the Petitioner receipt of the EOBR will be deemed to be 5 calendar days from the issue date on the EOBR.
2. Provide the name, mailing address, and certified mail receipt number for the copy of the Petition served, by United States
Postal Service certified mail, on the entity the Carrier designated on the Explanation of Bill Review to receive service of the
Petition on behalf of the Carrier and all affected parties. (If the Carrier did not designate on the EOBR the name and mailing
address of an entity to receive service of the Petition by certified mail, service of a copy of the petition by certified mail
shall be upon the entity that sent the EOBR.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3.
What specific issue(s) form the basis of the Petitioner's dispute of the Carrier's disallowance or adjustment of payment?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4.
What does the Petitioner assert is the correct reimbursement amount for the services that were disallowed or adjusted?
$ ________________
Attach to the Petition, a detailed calculation of the amount the Petitioner asserts is correct.
5.
Were the services for which payment was disallowed or adjusted provided pursuant to a reimbursement contract? _______
If yes, please provide a copy of the applicable provisions of the reimbursement contract with this Petition.
6.
Did the Petitioner submit all documentation requested in writing by or on behalf of the Carrier with regard to reimbursement
for the services in dispute? ___________
If not, please explain why the requested documentation was not provided.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
DFS Form 3160-0023 (effective 09/08/2006 - for use on or after 11/28/2006)
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