Dfs Form 3160-0024 Carrier Response To Petition For Resolution Of Reimbursement Dispute
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1
2Florida 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)
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