Florida Regulations 69L-10.0165

(2) All carriers, self-insurers, servicing agents, individuals or employers filing SDF-2�s with the SDTF shall provide the SDTF with all information required by these rules for each claim for reimbursement and the SDTF indicators, to permit a complete review of the entity's operation and processes. Such information may be furnished through hard copy or through a computer format as long as the information is made available to the SDTF at the time of the audit. In the event the information is kept in a format other than hard copy, such format shall be accessible by the SDTF without unreasonable delay caused by access codes or the programming of access code for entry into the entity�s database by the SDTF.

(3) SDTF indicators:

(a) Correct application of the offer;

(b) Properly filled out |^SDF-2|;

(c) Actual payment of benefits claimed;

(d) Correct calculation of benefits paid; (e) Reduction of medical charges in accordance with the fee schedule/reimbursement manual;

(f) Reduction of hospital charges in accordance with the fee schedule/reimbursement manual;

(g) Casual relation of benefits paid to the accident which formed the basis of the claim for reimbursement from the SDTF;

(h) Overpayments, underpayments or gratuitous payments made;

(i) Duplicate charges;

(j) Compliance with applicable statutes and rules governing managed care;

(k) Documentation as required by these rules.

(4) During an on-site audit, the entity being audited shall provide the following for review by the SDTF:

(a) The claims file subject to the limitations in Section 381.004, F.S.;

(b) A list of authorized providers, including name, address, and provider license number; (c) A medical bill, an |^SDF-6|, or its equivalent for each medical payment claimed for reimbursement;

(d) The financial detail corroborating each payment made to the claimant or the provider;

(e) Information establishing that type of managed care arrangement being utilized;

(f) For managed care arrangements, provide methodology used to calculate payments to providers.

Specific Authority 440.49(7) FS. Law Implemented 440.49(7) FS. History-New 12-8-98, Formerly 38F-10.0165, 4L-10.0165.