PIP Claims in Florida – Telaclaims LMS

Back to: TelaClaims Adjuster I – Insurance Basics for Adjusting a Claim

Personal Injury Protection Overview:

PIP is a type of no-fault insurance coverage that pays medical bills and lost wages in the event of a Florida accident.
PIP is an extension of vehicle insurance that’s available in some U.S states, but not mandatory in all of them. In Florida, some form of PIP coverage is required.
PIP covers any type of accident or injury that involves a vehicle, even if you yourself were not inside a vehicle. This means that even if you were a pedestrian or bicyclist at the scene of the accident, PIP can still apply to your accident case.
PIP can cover medical expenses, and in some cases, lost wages and other damages, such as rehabilitation costs, funeral cost and service replacement of someone injured in a covered car accident.

Personal Injury Protection in the State of Florida:

Under Florida law, it is required that every vehicle owner and driver has $10,000 worth of PIP insurance coverage.
Under PIP, automobile insurance carriers will cover up to 80% of medical bills, up to a max of $10,000, if Plaintiff seeks medical treatment within 14 days and his/her injuries were determined to be an emergency medical condition.
If you are involved in an accident in Florida(or any of the other states that require PIP coverage), PIP benefits will be paid by your insurance company, no matter who was the person at fault. This is why Florida is called a “no-fault insurance state”.

How to handle a Florida PIP Claim: An Adjuster’s Perspective

PIP adjusters must possess the ability to synthesize large amounts of information quickly and efficiently and maintain healthy working relationships with policyholders, co-workers, and attorneys despite the alternative perspectives and opinions of all parties involved in settling claims. Other requirements include strong written and verbal communication skills, bargaining skills, familiarity with basic office software, proficiency with claims systems, critical thinking, and problem-solving skills, the ability to develop and maintain amicable negotiations and an extensive knowledge of laws relating to insurance policies and claims. Every investigation starts with “What, who, where, when and how”. What?= Accident Who?= Claimants involved in the 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 claim from mailing letters, submitting request for payments, entering the bills into a system, responding to demand letters (many times PIP Litigation Adjuster will handle the claim once there is a demand (pre-suit), etc.

How to work a PIP claim:

As soon as you have an opportunity to 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 of their statements 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 were 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 about the facts of the accident/loss: You need to know what vehicles were involved 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 ensures 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 any medical 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, follow 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 the 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 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: The 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 Tools: Run a search on the policy address to see 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 asked 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”. 5) Letters Sent to Insured/Claimants: Whether or not you or your assistant mail 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 questioned 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 the 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 about coverage information via correspondence (via fax and/or mail). Inquire with your manager and/or supervisor as to how 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 postmark 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 75day open window to which submit bills from the first date of treatment. If there is no IOT of a 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 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. When automobile 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 same household, 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 an inability to work approximately 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. 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. Florida Statute 627.736 Important Sections for PIP Adjusters: 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 person to 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 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 treatment 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 Part A 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. 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 services from 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 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 every written 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 s 627.736(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. The 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. Each licensed insurer whether, domestic, foreign or alien shall file with the official designation of the name and address of the person to whom notice 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 workers’ 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 written notice 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. 3.An entity wholly owned by one or more physicians licensed under 458 (MD), 459(Osteopathic) or a Chiropractor 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 healthcare clinic licensed under 400.990-400.995 that is; a. Accredited by the JCAHO, the American Osteopath 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 lost 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). 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 of the 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 an 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 a 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 the provider). Box 29- This box indicates the amount that has been paid to the provider if any. Box 30- This box indicates the total amount due to the 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 the patient. (Provider’s demographic) **Box 33-Physician’s demographics. (Normally repeats information contained in box 32) ** Important Sections** This form can be found at the Centers for Medicare & Medicaid Services website: http://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10 REFERENCES: 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&filterByDID=-99&sortByDID=1&itemID=CMS1188854&intNumPerPage=10

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