A FLORIDA ADJUSTER'S BASIC GUIDE TO PIP CLAIMS[1].pdf

8/15/2019 A FLORIDA ADJUSTER'S BASIC GUIDE TO PIP CLAIMS[1].pdf

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B y : R.C. B u s t a m a n t e

2011

A Florida Adjuster’s

Basic Guide to PIP Claims


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Written by R.C. Bustamante- Request Permission Before Copying 2

Table of Contents:

Page 3- About Me

Page 4- How to work a PIP Claim- Initial Contact & Police Reports

Page 5- How to work a PIP Claim- ISO Search, Investigation Tool & Letters Sent to Claimants

Page 6- How to work a PIP Claim- continuation Letters Sent to Claimants, Providers & Medical

Bills

Page 7- How to work a PIP Claim- continuation Medical Bills, Death Benefits & Demands

Page 8- How to work a PIP Claim- continuation of Demands

Page 9- How to work a PIP Claim- PIP Adjuster Dictionary

Page 10- How to work a PIP Claim- Auto Policy Coverage’s

Page 11-16 – How to work a PIP Claim- Florida Statute 627.736 Important Sections for PIP

Adjuster’s

Page 17- How to work a PIP Claim- Billing CMS 1500 Form

Page 18- Reference Page


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About me:

Insurance is a field that offers so many wonderful career opportunities. I obtained my Accredited

Claims Adjuster Designation March of 2004. I hold a Bachelors’ Degree in Legal Studies, a

two year degree in Medical Insurance Billing & Coding, Certificate in Healthcare Risk

Management. My professional experience has been in the Healthcare Field as: PIP andLitigation PIP Adjuster and SIU Investigator in the insurance industry. It all started in PIP though!

I write this manual for you, my adjuster colleagues! Insurance is my passion and I know walking

up the insurance career ladder will not be easy but YOU will get there. I invite you to read on

and allow yourself to absorb this information and use it as a guide. Remember every insurance

carrier writes different types of insurance policies; but in Florida they all offer basic coverage

which contains PIP, PD and BI. If additional coverage’s are available to purchase , individuals

may do so by contacting an agent. Once you feel comfortable, find your way and adjust claims in

your rhythm while following your company’s rules and guidelines and always to the standards

set in Florida Statute. Don’t forget the claims assigned in your name represent you and youradjuster license! Be respectful, mindful and courteous to everyone including your colleagues.

You will learn all you need to know with regard to PIP on the job, hands-on, ask many questions

and take plenty notes. I wish you luck and success in your insurance endeavors!

Feel free to reach me via email (comments and/or questions are always welcome) @

[email protected].

Every investigation starts with “What, who, where, when and how”.

What= Accident

Who= Claimants involved in loss

Where= Where did this accident occur

When= When did this accident occur

How= How did this accident occur

You are the Personal Injury Protection (PIP) claims adjuster and your goal is to ensure that the

injuries, treatment, and facts all add up. As you will be dealing with the medical aspect of a

claim, invest in a medical dictionary so you can familiarize yourself with medical terms.

Every insurance company works differently; some insurance carriers have certain personnel

assigned to certain tasks and the adjuster is just set in place to deny or clear coverage, where

other insurance carriers have the insurance adjuster responsible for all aspects of the PIP claimfrom mailing letters, submitting request for payments, entering the bills into a system,

responding to demand letters (many times PIP Litigation Adjuster’s will handle the claim once

there is a demand (pre-suit)), etc.

mailto:[email protected]:[email protected]


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How to work a PIP claim:

As soon as you have an opportunity ask your manager or supervisor for a copy of the company’s

policy jacket (trust me this will come in handy).

1) Initial Contact: Contact the insured to obtain all the facts concerning the accident/loss.

You will need to ask them some serious questions, don’t be scared, it is just a

conversation where you are trying to help them help you! Ask them what happened (for

example: who was involved in the accident, what vehicle was involved in the accident,

who was driving the vehicle, were there any passengers, who was at fault for the

accident, were there any injuries, if there were injuries who was injured, was law

enforcement called, did anyone go to the hospital, etc.)

Note: If you receive a letter of representation from an attorney indicating they represent

your insured or any claimant, do not contact the insured and/or claimant. You must

contact the attorney’s office! If the insured and/or claimant that are represented should

contact you via telephone kindly advise them to contact their attorney!

a) Why you inquire to the facts of the accident/loss: You need to know what vehicles wereinvolved in the accident to ensure the vehicle is insured by your insurance company, you

need to know who was driving the vehicle to see if they are listed on the policy written by

your insurance company, you need to know if there were any passengers (you will need

to know if they are related to your insured and if they live with your insured-refer to

Florida Statute 627.732 for definitions of “named insured” and “relative residing in the

same household”), you need to know if there was or were any other vehicles involved in

this accident that way you can contact the insurance carrier who insures those or that

vehicle (contact the other insurance carrier adjusters and see what information they can

share with you; such as photos of the vehicle insured by your insurance carrier), you need

to know if there were injuries and if those injured are treating or were treated by anymedical provider, you need to know if any of the claimants lost time from work (loss

wages) due to the accident, and lastly you need to know if the vehicle has been repaired

and by whom (body shop).

Note: Always send out a PIP application package to the named insured and claimants

involved in loss requesting PIP coverage.

2) Police Reports: Check to see if a police report was provided. If one has not

been provided, check to see if the police report number was provided by the person

who reported the accident to your insurance company. If you have a police report number

and what jurisdiction responded to the scene, f ollow your company’s rules and guidelines

as to how they would like you to proceed in obtaining a copy of the police report. You can

request a copy from the following: the named insured and/or claimant- upon the initial

phone call made by you to determine facts of the accident, the named insured and/or

claimant’s attorney, the provider’s office where the names insured and/or claimant is

treating, insurance carrier for the other party(s) involved in the accident, and/or directly


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from the law enforcement jurisdiction who responded to the scene (you may want to call

ahead to see how much it will cost to obtain a copy of the police report).

3) ISO Searches: Database used to search for any PIP, BI (Bodily Injury) or WC (Workers’

Comp) claims filed in the past (look for trends in these search results). Insurance carriers

input information into this database when an accident occurs.

For further inquiries regarding ISO searches and the database which you will you use for

these searches, ask you manager or supervisor.

4) Investigation Tool: Run a search on the policy address to see who who resides in the

insured policy address and what unlisted vehicles are in the insured policy address: you

will start by 1st running a search on the address, 2nd running a search on the driver’s

license attached to the address, and lastly 3rd run the vehicles attached to the address.

Each insurance company has their own search system that they use. Inquire with your

manager or supervisor to see what company they use for these type of searches.a) Why you run this search: This database search is done to see if the information contained

in the policy is true and correct. If a licensed individual resides in the household and is

not listed on the policy they create an AP (additional premium) to the policy, the same is

said for any vehicles that are garaged at the insured policy address but yet are not listed

on the policy.

Florida Law requires any licensed individual who has a vehicle registered in their name

obtain automobile insurance!

Note: List in your notes the “ possible” drivers, persons, and vehicles that appear in the

results 3 to 4 months prior to the policy inception date up to the date you are running the

search. (Put in your notes POSSIBLE) You can’t deny the claim based solely on your search, you would need to inquire with the named insured to rule in or out if these

individuals and/or vehicles you found do reside and/or are garaged in the insured policy

address.

For search results 3 to 4 months prior to policy inception **Caution**: Underwriting

should have run their own search prior to writing the insurance policy to avoid AP’s at

the stage of a claim. Ask your manager or supervisor to provide you a copy of the

company’s policy application so you can see what questions insured’s are ask ed prior to

obtaining a policy.

Individuals that reside in the household who do not hold a driver’s license generally do

not create high amount AP’s.

Premium- The amount an individual pays when they initially obtain insurance coverage

through an insurance carrier is called a “premium”, when any additional amounts are

made to the policy the amount is called an “additional premium”.


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5) Letters Sent to Insured/Claimants: Whether or not you or your assistant mails out the

following is based on your investigation: ROR- Reservation of Rights letter (where

insurance company reserves the right to deny all or a partial amount of the claim), EUO-

(Examination under Oath) appointment, and/or IME (Independent Medical Examination)

appointment. Follow the protocol your insurance company has set in place with regard to

how they would like you to mail these letters/appointments.

IME appointments- This is a medical appointment. If during the course of your

investigation (early on in the investigation) you should send a claimant to an IME

appointment, ensure you send them to a doctor who holds the same specialty as the

doctor they are currently treating with.

EUO appointments- This is an appointment in which insured and/or claimants are

questioned in person under oath in front of a court reporter as to the facts of the accident.

The insured and/or claimants are usually question by the insurance company SIU adjuster

or insurance company attorney. The insured and/or claimant have the right to have their

attorney present; the attorney can be present via telephone or in person.

6) Provider(s): Ensure you always indicate via correspondence the status of the claim with

provider(s). Providers will contact you via telephone and/or correspondence to inquire the

following: coverage inquiries (they will inquire to ensure there is coverage for the

medical bills which they shall be mailing), status of the claim (whether it is still in the

investigation status and/or if coverage has been cleared), and to inquire the status of their

medical bills (whether they are going to be paid and /or denied).

Some insurance carriers provide coverage information to the provider via telephone and

other insurance carriers would like for the provider to inquire coverage information via

correspondence (via fax and/or mail). Inquire with your manager and/or supervisor as tohow they would like for you to discuss coverage issues with the provider whether by

phone or mail or both.

7) Medical Bills: Cross check the post mark date on the envelope and date stamp that the

mail personnel in your insurance company stamped to note when the bills were received.

Initiation of Treatment (IOT) letter ’s must be received in the insurance company’s office

before the 21st day from the first date of treatment in order for the provider to have the 75

day open window to which submit bills from the first date of treatment.

If there is no IOT of letter received, the first set of bills (meaning bills from the first date

of service) must be received within 35 days.

When you receive medical bills ensure the provider has submitted a Disclosure and

Acknowledgment Form. Florida Statute 627.736 (5)(e) states “At the initial treatment or

service provided, each physician, other licensed professional, clinic, or other medical

institution providing medical services upon which a claim for PIP benefits is based shall

require an insured person, or his or her guardian, to execute a disclosure and


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acknowledgment form…” Florida Statute requires the provider submits the original

Disclosure & Acknowledgment Form to the insurance company. (Make sure you have an

original).

Emergency Services & Care Bills: Follow Florida Statute 627.736 (4)(c) which states

“The insurer must reserve 5k of PIP benefits for payment to physicians licensed under

chapter 458 (MD) or chapter 459 (Osteopathic) or dentists licensed under chapter 466

who provide emergency services and care, as defined in s.s. 395.002(9), or who provide

hospital inpatient care. The amount required to be in reserve may be used only to pay

claims from such physicians or dentists until 30 days after the date the insurer receives

notice of the accident. After the 30-day period, any amount of the reserve for which the

insurer has not received notice of a claim from a physician or dentist who provided

emergency services and care or who provided hospital inpatient care may then be used by

the insurer to pay other claims…”

8) Death Benefits: This is the hardest and most difficult part of being a PIP adjuster. Whenautomobile accidents occur there is a great chance of there being fatalities. If you become

emotional it is okay, you are human! If you do come across a claim where there are

fatalities follow Florida Statute 627.736 (1)(c) which states “…Death benefits equal to

the lesser of the 5k or the remained of unused PIP benefits per individual. The insurer

may pay such benefits to the executor or administrator of the deceased, to any of the

deceased’s relatives by blood or legal adoption or connection by marriage, or to any

person appearing to the insurer to be equitably thereto…”

Note: Follow Florida Statute 627.736 (1) “Required Benefits” which states “ Every

insurance policy…shall provide PIP to the named insured, relatives residing in the samehousehold, persons operating the insured motor vehicle, passengers in such motor

vehicle, and other persons struck by such motor vehicle and suffering bodily injury while

not an occupant of a self-propelled vehicle, subject to the provisions of subsection (2) and

paragraph (4)(e) to a limit of 10k for loss sustained as a result of bodily injury, sickness,

disease, or death arising out of the ownership, maintenance, or use of a motor vehicle as

follows:

Medical Benefits- 80% of all reasonable expenses for medically necessary medical,

surgical, x-ray, dental and rehab. services including prosthetic devices, and medically

necessary ambulance, hospital, and nursing services…

Disability Benefits- 60% of any loss of gross income and loss of earning capacity per

individual from inability to work proximately caused by the injury sustained by the

injured person, plus all expenses reasonably incurred…All disability benefits payable

under this provision shall be paid not less than every 2 weeks…”

Death Benefits- see #8 for further.


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9) Demands: This is the pre-suit stage. When a provider submits medical bills and they are

not paid the provider can submit to the insurance company a demand letter. The demand

letter should follow Florida Statute 627.736(10) (b) and Florida Statute 627.726 (10)(c),

this statute contains the responsibilities for the provider and how they must submit the

demand. The insurance carrier is also responsible for interest, penalty and postage for

bills not paid within the time frame set in place by statute (See Florida Statute 627.736

(4)(d) & Florida Statute 627.736(10) (c))

As mentioned in Florida Statute 627.736(4)(b)”…PIP benefits shall be overdue if not

paid within 30 days after the insurer is furnished with written notice of the fact of a

covered loss and of the amount of the same…”

As I indicated previously some insurance carriers have Litigation PIP Adjusters handle

the claim once it is in this stage


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Written by Rhina C. Bustamante- Request Permission Before Copying 9

PIP Adjuster Dictionary: (most commonly used terms and their meaning)

Insd= Insured

N/I= Named Insured

I/V= Insured Vehicle

VOP= Vehicle on Policy

Clmnt= Claimant

O/V= Other Vehicle

O/P= Other Party

DOL= Date of Loss

U/W= Underwriting

AP= Additional Premium

DNOP= Driver Not Listed on Policy

VNOP= Vehicle Not Listed on Policy

AOB= Assignment of BenefitsD&A= Disclosure and Acknowledgment Form

IOT= Initiation of Treatment

IME= Independent Medical Examination

EUO= Examination Under Oath

S/S= Sworn Statement

R/S= Reschedule and/or Recorded Statement

C/O= Cut-off

Attny= Attorney

Adj= Adjuster

MVR= Motor Vehicle Run (Driving Records)PIP Log= Log that is maintained by the PIP adjuster. This log contains information regarding

medical bills: this log should specify when (date) bill was paid or denied, the original amount of

the bill, bill amount after applied to fee schedule, bill amount after applied to 80%, bill amount

after applied to deductible. Each individual will have their own separate PIP log.

EOB= Explanation of Benefits

H/H= Household

MM= Material Misrepresentation

P/R= Police Report

LOR= Letter of Representation

Florida Statute 627.732 is an excellent statute to print for further definition. Print this statute

and place by your desk!


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Auto Policy Coverage’s: Check with your insurance company’s underwriting department if you

have any questions with regard to the policy coverage’s.

PD= Property Damage (This coverage covers vehicles or property that the policy holder

damages)

BI= Bodily Injury (This covers other persons that are injured, not those listed in the policy or

resident relatives of those listed in the policy)

PIP= Personal Injury Protection (This covers injuries to the policy holder, listed drivers and

resident relatives of the policy holder)

UM= Uninsured Motorists

COMP= Comprehensive

COLL= Collision

COMP/COLL= (This covers damage to the vehicle listed on the policy)

Note: COMP/COLL coverage can’t be purchased separately. If an individual has COMP

automatically know they also have COLL.


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Florida Statute 627.736 Important Sections for PIP Adjuster’s: This statute should be printed

and placed by your desk!

Reporting of loss:

Fla Statute 627.736 (4)(a) An insurer may require written notice to be given as soon as

practicable after an accident involving a motor vehicle with respect to which the policy affords

the security required by s.s. 627.730-627.7405

EOB and/or Denial:

Fla Statute 627.736 (4)(b) When an insurer pays only a portion of a claim or rejects a claim, the

insurer shall provide at the time of the partial payment or rejection an itemized specification of

each item that the insurer had reduced, omitted, or declined to pay and any information that the

insurer denies the claimant to consider related to the medical necessity of the denied treatment or

to explain the reasonableness of the reduced charge, provided that this shall not limit the

introduction of evidence at trial; and the insurer shall include the name and address of the personto whom the claimant should respond and a claim number to be referenced in future

correspondence.

1st 30 days 5k Reserves:

Fla Statute 627.736 (4)(c) The insurer must reserve 5k of PIP benefits for payment to physicians

licensed under chapter 458 (MD) or chapter 459 (Osteopathic) or dentists licensed under chapter

466 who provide emergency services and care, as defined in s.s. 395.002(9), or who provide

hospital inpatient care.

After the 30-day period, any amount of the reserve for which the insurer has not received notice

of a claim from a physician or dentist who provided emergency services and care or who provided hospital inpatient care may then be used by the insurer to pay other claims.

Interest:

Fla Statute 627.736 (4)(d) All overdue payments shall bear simple interest at the rate established

under s.s 55.03 or the rate established in the insurance contract, whichever is greater, for the year

in which the payment became overdue, calculated from the date the insurer was furnished with

written notice of the amount of the covered loss. Interest shall be due at the time payment of the

overdue claim is made.

Insurance Fraud:

Fla Statute 627.736 (h) Benefits shall not be due or payable to or on the behalf of an insured

person if that person has committed, by a material act or omission, any insurance fraud relating

to PIP coverage under his or her policy, if the fraud is admitted to in a sworn statement by the

insured or if it is established in a court of competent jurisdiction. Any insurance fraud shall void

all coverage arising from the claim related to such fraud under the PIP coverage of the insured



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Written by R C. Bustamante- Request Permission Before Copying 12

person who committed the fraud, irrespective of whether a portion of the insured person’s claim

may be legitimate and any benefits paid prior to the discovery of the insured person’s insurance

fraud shall be recoverable by the insurer from the person who committed insurance fraud in their

entirety.

Charges for treatment of injured persons:

Fla Statute 627.736 (5) The insurer may limit reimbursement to 80 % of the following schedule

of maximum charges:

(a)- For ER transport and txmnt by providers licensed under chapter 401, 200% of Medicare

(b)- For ER services and care provided by a hospital licensed under chapter 395, 75% of the

hospital’s usual and customary charges.

(c)- For ER services and care as defined by s. 395.002(9) provided in a facility licensed under

chapter 395 rendered by a physician or dentist, and related hospital inpatient services rendered

by a physician or dentist, the usual and customary charges in the community.

(d)- For hospital outpatient services, other than ER services and care, 200% of the Medicare partA prospective payment applicable to the specific hospital providing the inpatient services.

(e)- For hospital outpatient services, other than ER services and care, 200% of the Medicare part

A prospective payment applicable to the specific hospital providing the inpatient services.

(f)- For all medical services, supplies, and care, 200% of the allowable amount under the

participating physicians schedule of Medicare Part B. However, if such services, supplies or care

is not reimbursable under Medicare Part B, the insurer may limit reimbursement to 80% of the

maximum reimbursable allowance under workers’ compensation, as determined under s. 440.13

and rules adopted thereunder which are in effect at the time such services, supplies, or care is

provided. Service, supplies, or care that is not reimbursable under Medicare or workers’

compensation is not required to be reimbursed by the insurer.

21 Day IOT- 35/75 Submission of claims rules:

Fla Statute 627.736 (5)(c) With respect to any treatment or service, other than medical services

billed by a hospital or other provider for ER services as defined in s. 395.002 or inpatient

services rendered at a hospital-owned facility, the statement of charges must be furnished to the

insurer by the provider and may not include, and the insurer is not required to pay charges for

treatment or services rendered more than 35 days before the postmark date or electronic

transmission date of the statement, except for past due amounts previously billed on a timely

basis under this paragraph, and except that, if the provider submits to the insurer a notice of

initiation of treatment within 21 days after its examination or treatment of the claimant, the

statement may include charges for treatment or services rendered up to, but not more than 75

days before the postmark date of the statement.


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Box 31: (CMS 1500 Form)

Fla Statute 627.736 (5)(d) All providers other than hospitals shall include on the applicable claim

form the professional license number of the provider in the line, or space provided for “Signature

of Physician or Supplier, Including degrees or credentials”.

Disclosure & Acknowledgment Form:

Fla Statute (5)(e) At the initial treatment or service provided, each physician, other licensed

professional, clinic, or other medical institution providing medical services upon which a claim

for PIP benefits is based shall require an insured person, or his or her guardian, to execute a

disclosure and acknowledgment form, which reflects at a minimum that:

(e)(1)(a) The insured, or his or her guardian, must countersign the form attesting to the fact that

the services set forth therein were actually rendered;

(e)(1)(b) The insured, or his or her guardian, has both the right and affirmative duty to confirm

that the services rendered were actually rendered;

(e)(1)(c) The insured, or his or her guardian, was not solicited by any person to seek any servicesfrom the medical provider;

(e)(1)(d) The physician, other licensed professional, clinic, or other medical institution rendering

services for which payment is being claimed explained the services to the insured or his or her

guardian;

(e)(1)(e) If the insured notifies the insurer in writing of a billing error, the insured may be

entitled to a certain percentage of a reduction in the amounts paid by the insured’s motor vehicle

insurer.

Fla Statute (5) (e) (5) The original disclosure and acknowledgment form shall be furnished to the

insurer pursuant to paragraph (4) (b) and may not be electronically furnished.

Informed Consent:

Fla Statute (5)(e)(2) The physician, other licensed professional, clinic or other medical institution

rendering services for which payment is being claimed has the affirmative duty to explain the

services rendered to the insured, or his or her guardian, so that the insured, or his or her guardian,

countersigns the form with informed consent.

Improper Billing:

Fla Statute (5) (f) Upon written notification by any person, an insurer shall investigate any claim

of improper billing by a physician or other medical provider. The insurer shall determine if the

insured was properly billed for only those services and treatments that the insured actually

received. If the insurer determines that the insured has been improperly billed, the insurer shall

notify the insured, the person making the written notification and the provider of its findings and

shall reduce the amount of payment to the provider by the amount determined to be improperly

billed. If a reduction is made due to such written notification by any person, the insurer shall pay

to the person 20% of the amount of the reduction, up to $500.00. If the provider is arrested due to



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Written by Rhina C. Bustamante- Request Permission Before Copying 14

the improper billing, then the insurer shall pay to the person 40% of the amount of the reduction,

up to $500.

Loss Wage Form:

Fla Statute (6)(a) Each employer shall, if a request is made by an insurer provider PIP benefits

under ss. 627.730-627.7405 against whom a claim has been made, furnish forthwith, in a form

approved by the office, a sworn statement of the earnings, since the time of the bodily injury and

for a reasonable period before the injury, of the person upon whose injury the claim is based.

IME Appointments:

Fla Statute (7)(b) If requested by the person examined, a party causing an examination to be

made shall deliver to him or her a copy of every written report concerning the examination

rendered by an examining physician, at least one of which reports must set out the examining

physicians’ findings and conclusions in detail. After such request and delivery, the party causing

the examination to be made is entitled, upon request to receive from the person examined everywritten report available to him or her or his or her representative concerning any examination,

previously or thereafter made, of the same mental or physical condition. By requesting and

obtaining a report of the examination so ordered, or by taking the deposition of the examiner, the

person examined waives any privilege her or she may have, in relation to the claim for benefits,

regarding the testimony of every other person who has examined, or may thereafter examine him

or her in respect to the same mental or physical condition. If a person unreasonably refuses to

submit to an examination, the PIP carrier is no longer liable for subsequent PIP benefits.

Demands:

Fla Statute 627.736(10) (b) The notice required shall state that it is a “demand letter under s627.736(10)” and shall state with specificity:

1. The name of the insured upon which benefits are being sought, including a copy of the

assignment giving rights to the claimant if the claimant is not the insured.

2. The claim number or policy number upon which such claim was originally submitted to

the insurer.

3. To the extent applicable, the name of any medical provider who rendered to an insured

the treatment, services, accommodations, or supplies that form the basis of such claim;

and an itemized statement specifying each exact amount, the date of treatment, service, or

accommodation, and the type of benefit claimed to be due.

Mailing requirement for Demands:

Fla Statute 627.736(10) (c) Each notice required by this section must be delivered to the insurer

by USPS certified or registered mail, return receipt requested. Such postal costs shall be made

reimbursed by the insurer if so requested by the claimant in the notice, when the insurer pays the

claims.


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Each licensed insurer whether, domestic, foreign or alien shall file with the office designation

of the name and address of the person to whom notices pursuant to this subsection shall be

sent which the office shall make available on its Internet website.

Penalty Payments with regard to Demands:

Fla Statute 627.736(10) (d) If, within the 30 days after the receipt of notice by the insurer, the

overdue claim specified in the notice is paid by the insurer together with applicable interest and a

penalty of 10% of the overdue amount paid by the insurer, subject to a maximum penalty of

$250, no action may be brought against the insurer.

Insurers Not Paying Valid Claims:

Fla Statute 627.736(10)(f) Any insurer making a general business practice of not paying valid

claims until receipt of the notice required by this subsection is engaging in an unfair trade

practice under the insurance code.

Benefits:

Fla Statute 627.736(4) Benefits due from an insurer under 627.730-627.7405 shall be primary,

except that benefits received under worker s’ compensation law shall be credited against the

benefits provided by subsection (1) and shall be due and payable as loss accrues, upon receipt of

reasonable proof of such loss and the amount of expenses and loss incurred which are covered by

the policy. When AHCA provides, pays, or becomes liable for medical assistance under

Medicaid related to injury, sickness, disease, or death arising out of the ownership, maintenance,

or use of a motor vehicle, benefits under 627.730-627.7405 shall be subject to the provisions of

the Medicaid program.

PIP benefits shall be overdue if not paid within 30 days after the insurer is furnished writtennotice of the fact of a covered loss and of the amount of the same. If such written notice is not

furnished to the insurer as to the entire claim, any partial amount supported by written notice is

overdue if not paid within 30 days after such written notice is furnished to the insurer. Any part

or all of the remainder of the claim that is subsequently supported by written notice is overdue if

not paid within 30 days after such written notice is furnished.

Medical- 80% of all reasonable expenses for medically necessary surgical, x-ray, dental, and

rehab services including prosthetic devices, and medically necessary ambulance, hospital and

nursing services. The medical benefits shall provide reimbursement only for such services and

care that are lawfully provided, supervised or prescribed by a physician licensed under chapter

458(MD), 459 (Osteopathic), a dentist licensed under 466 or a Chiro licensed under 460 or are

provided by any of the following:

1. A hospital or ambulatory surgical center licensed under 395.

2. A person or entity licensed under 401-2101-401-45.


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3. An entity wholly owned by one or more physicians licensed under 458 (MD), 459

(Osteopathic) or a Chiro under 460, or a dentist licensed under 466 or by such

practitioner or practitioners and the spouse, child, or sibling of that practitioner or those

practitioners.

4. An entity wholly owned directly or indirectly by a hospital or hospitals.

5. A health care clinic licensed under 400.990-400.995 that is;

a. Accredited by the JCAHO, the American Osteo Association, the Commission on

Accreditation of Rehab Facilities or the Accreditation for Ambulatory Health Care or

a healthcare clinic that:

b. Has a medical director licensed under 458 (MD), 459 (Osteopathic) or 460

(Chiropractic).

c. Has been continuously licensed for more than 3 years or is a publicly traded corp that

issues securities traded on an exchange registered with the US Securities & Exchange

Commission.

Provides at least four of the following medical specialties:a. General medicine

b. Radiography

c. Ortho medicine

d. Physical medicine

e. Physical therapy

f. Prescribing or dispensing outpatient prescription medication

g. Laboratory services

Disability Benefits- 60% of any loss wages or gross income and loss of earning capacity per

individual from inability to work proximately caused by the injury sustained by the injured person, plus all expenses reasonably incurred in obtaining from others ordinary and necessary

services in lieu of those that but for the injury the injured person would have performed without

income for the benefit of his or her household. All disability benefits payable under this

provision shall be paid not less than every 2 weeks.

Death Benefits- Death benefits equal to the lesser of the 5k or the remained of unused PIP

benefits per individual. The insurer may pay such benefits to the executor or administrator of the

deceased, to any of the deceased’s relatives by blood or legal adoption or connection by

marriage, or to any person appearing to the insurer to be equitably thereto.

Reference: § 627.736, Fla. Stat. (2010) & § 627.732, Fla. Stat. (2010).


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BILLING (CMS 1500): (Providers form to submit services rendered)

Box 1: An X should be placed where “other” is indicated.

**Box 2- Box 8 should indicate the patient (who can also be the insured’s) demographic

information.

Note: If the insured is other than the patient such as a spouse or child this is a good place to

check relationship status.

Box 9-11d will indicate the Insurance Company’s information inclusive of a claim or police

number.

Box 12- Patient’s signature. (Normally there is no signature but rather it will state “Signature on

File”)

Box 13- Insured’s signature. (Normally there is no signature but rather it will state “Signature on

File”)

Box 14- This should state the date when the accident/incident occurred.

Box 15-17- Are usually left blank.

**Box 17- This box should indicate the name of the referring physician. (Meaning the name ofthe MD/DC/DO who referred the patient to this facility- the facility that is using the form to bill

the insurance carrier) If left blank- the provider is indication the patient was not referred to them.

Box 18- 20- Are usually left blank.

**Box 21- This box should indicate the nature of the illness or injury. (Reason patient is seeking

treatment)- Nature of illness or injury will be indicated by ICD Codes.

Box 22-23- Are usually left blank.

**Box 24- This box should indicate the dates, charge amount and services rendered to the patient

while in the facility. Services rendered will be indicated by CPT Codes.

**Box 25- Provider’s federal tax ID number.

Box 26- This box indicates the patients account number for provider that is billing.**Box 27- This box should indicate if the provider is accepting an assignment of benefits.

(Meaning benefits will be paid directly to the provider)

Box 28- This box indicates the total amount charged (what is to be paid to provider).

Box 29- This box indicates amount that has been paid to provider if any.

Box 30- This box indicates the total amount due to provider.

**Box 31- This box is one that has been constantly debated in courts between providers

attorney’s and insurance carrier’s attorney. (Refer to Fla Statute 627.736 (5) (d))

**Box 32- Name and address where services were rendered to patient. (Provider’s demographic)

**Box 33-Physician’s demographics. (Normally repeats information contained in box 32)

** Important Sections**

This form can be found at Centers for Medicare & Medicaid Services website:

http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-

99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10

http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10


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REFERENCE PAGE

Florida Statute § 627.736, Fla. Stat. (2010) § 627.732, Fla. Stat. (2010).

Retrieved via internet May 2011: http://www.leg.state.fl.us/Statutes/

U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services-CMS 1500 Form

Retrieved via internet May 2011:

http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDI

D=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10
http://www.leg.state.fl.us/Statutes/http://www.leg.state.fl.us/Statutes/http://www.leg.state.fl.us/Statutes/http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10http://www.leg.state.fl.us/Statutes/

Documents

A FLORIDA ADJUSTER'S BASIC GUIDE TO PIP CLAIMS[1].pdf