Instructions for Form DFS-F5-DWC-9 "Health Insurance Claim Form (Licensed Health Care Providers)" - Florida

This document contains official instructions for Form DFS-F5-DWC-9, Health Insurance Claim Form (Licensed Health Care Providers) - a form released and collected by the Florida Department of Financial Services.

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DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
1.
TYPE OF CLAIM
NOT REQUIRED
NO
1a.
INSURED’S I.D.
REQUIRED
Enter the Social Security Number or the
YES
NUMBER
Division-Assigned Number of the injured
employee. If the Social Security Number is
unknown and the Division-Assigned Number is
also unknown, the provider must contact the
insurer/claim administrator to obtain the number.
2.
PATIENT’S NAME
REQUIRED
Enter injured employee’s last name, first name,
NO
and middle initial, if applicable.
3.
PATIENT’S BIRTH
REQUIRED
Enter injured employee’s date of birth in
NO
DATE AND SEX
MMDDYY format, and sex (M or F).
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Rule 69L-7.720, F.A.C.
Revised 01/01/2015
Page 1 of 11
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS’ COMPENSATION
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
1.
TYPE OF CLAIM
NOT REQUIRED
NO
1a.
INSURED’S I.D.
REQUIRED
Enter the Social Security Number or the
YES
NUMBER
Division-Assigned Number of the injured
employee. If the Social Security Number is
unknown and the Division-Assigned Number is
also unknown, the provider must contact the
insurer/claim administrator to obtain the number.
2.
PATIENT’S NAME
REQUIRED
Enter injured employee’s last name, first name,
NO
and middle initial, if applicable.
3.
PATIENT’S BIRTH
REQUIRED
Enter injured employee’s date of birth in
NO
DATE AND SEX
MMDDYY format, and sex (M or F).
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Rule 69L-7.720, F.A.C.
Revised 01/01/2015
Page 1 of 11
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
4.
INSURED’S NAME
REQUIRED
Enter the business name for the injured
NO
employee’s employer on the date entered in
Field 14.
5.
PATIENT’S
REQUIRED
Enter the injured employee’s complete mailing
NO
ADDRESS
address and telephone number in the appropriate
spaces:
Line 1 – Enter the street address, including
apartment number if applicable;
Line 2 – Enter the city and state;
Line 3 – Enter the zip code and telephone
number including area code.
6.
PATIENT
NOT REQUIRED
NO
RELATIONSHIP TO
INSURED
7.
INSURED’S
REQUIRED
Enter the complete business address of the
NO
ADDRESS
employer entered in Field 4:
Line 1 – Enter the street address, including suite
number if applicable;
Line 2 – Enter the city and state;
Line 3 – Enter the zip code and telephone
number.
8.
RESERVED FOR
NOT REQUIRED
NO
NUCC USE
9.
OTHER INSURED’S
NOT REQUIRED
NO
NAME
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Revised 01/01/2015
Page 2 of 11
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
9a.
OTHER INSURED’S
NOT REQUIRED
NO
POLICY OR GROUP
NUMBER
9b.
RESERVED FOR
NOT REQUIRED
NO
NUCC USE
9c.
RESERVED FOR
NOT REQUIRED
NO
NUCC USE
9d.
INSURANCE PLAN
NOT REQUIRED Completion of this field is optional. Provider
NO
NAME OR
may enter the insurer’s/claim administrator’s
PROGRAM NAME
telephone number including area code.
Enter an “x” in the appropriate box (A,B,C) to
NO
10.
IS PATIENT’S
REQUIRED
indicate whether any of the billed services are
CONDITION
(A, B.,C.)
for a condition covered by workers’
RELATED TO:
compensation insurance, an auto accident, or any
A. EMPLOYMENT
other accident type.
B. AUTO
ACCIDENT
C. OTHER
ACCIDENT
10d.
CLAIM CODES
CONDITIONAL
Enter Claim Codes as applicable.
NO
(DESIGNATED BY
NUCC)
11.
INSURED’S
NOT REQUIRED
NO
POLICY GROUP OR
FECA NUMBER
11a.
INSURED’S DATE
NOT REQUIRED
NO
OF BIRTH AND
SEX
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Revised 01/01/2015
Page 3 of 11
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
OTHER CLAIM ID
11b.
NOT REQUIRED
NO
(DESIGNATED BY
NUCC)
11c.
INSURANCE PLAN
NOT REQUIRED
NO
NAME OR
PROGRAM NAME
11d.
IS THERE
NOT REQUIRED
NO
ANOTHER HEALTH
BENEFIT PLAN?
NO
12.
PATIENT’S OR
NOT REQUIRED
AUTHORIZED
PERSON’S
SIGNATURE
13.
INSURED’S OR
NOT REQUIRED
NO
AUTHORIZED
PERSON’S
SIGNATURE
Enter the date of onset, in
NO
14.
DATE OF
REQUIRED
CURRENT
MMDDYY, i.e. date of first symptom or current
ILLNESS, INJURY,
accident, illness or injury.
OR PREGNANCY
(LMP)
NO
15.
OTHER DATE
NOT REQUIRED
16.
DATES PATIENT
NOT REQUIRED
NO
UNABLE TO WORK
IN CURRENT
OCCUPATION
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Revised 01/01/2015
Page 4 of 11
FORM DFS-F5-DWC-9-A COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
PHYSICIANS AND RECOGNIZED PRACTITIONERS SHALL COMPLETE THE DWC-9 ACCORDING TO
THESE INSTRUCTIONS AND SHALL ENTER THE INSURER/CLAIMS ADMINISTRATOR NAME, ADDRESS,
AND ZIP CODE IN THE BLANK AREA ON TOP OF THE DWC-9 (CMS-1500)
FIELD
FIELD NAME
FIELD STATUS
COMMENTS
SUBJECT TO
NO.
SEND BACK
POLICY
69L-7.740(11)(g)
17.
NAME OF
NOT REQUIRED
NO
REFERRING
PROVIDER OR
OTHER SOURCE
Enter the Florida Department of Health alpha-
NO
17a.
UNNAMED
CONDITIONAL
numeric license number of the referring health
care provider, if available.
17b.
NPI
NOT REQUIRED
NO
Enter “FROM” and “TO” dates, in
NO
18.
HOSPITALIZATION
CONDITIONAL
MMDDYY format, when a medical service is
DATES RELATED
furnished as a result of, or subsequent to, a
TO CURRENT
related hospitalization.
SERVICES
19.
ADDITIONAL
CONDITIONAL
Enter the word “ATTACHMENTS” If the claim
NO
CLAIM
form is accompanied by attachments(s) (e.g.,
INFORMATION
documentation of supply costs, medical records,
(DESIGNATED BY
etc.).
NUCC)
20.
OUTSIDE LAB
NOT REQUIRED
NO
Form DFS-F5-DWC-9-A
COMPLETION INSTRUCTIONS FOR
PHYSICIANS AND RECOGNIZED PRACTITIONERS
Revised 01/01/2015
Page 5 of 11