12 Fla. L. Weekly Supp. 570b
Insurance — Personal injury protection — Claim forms — Medical license number — Claim form containing medical provider’s medical license number in box 33 rather than box 31 substantially met statutory requirements for claims — Insurer’s motion for summary judgment denied
FLORIDA SPINECARE CENTER, a/a/o Bruce Campos, Plaintiff, vs. NATIONWIDE PROPERTY & CASUALTY INSURANCE COMPANY, Defendant. County Court, 9th Judicial Circuit in and for Orange County. Case No. 04-SC-7847. Division 71-P.I.P. March 23, 2005. Jerry L. Brewer, Judge. Counsel: Adam Ross Litman, Adam Ross Littman, P.A., Orlando, for Plaintiff. R. Scott Simmons, Law Offices of Capito & Polk, Lake Mary, for Defendant.
ORDER DENYING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT
THIS CAUSE came before this Court on March 4, 2005 on the Motion for Summary Judgment filed by Defendant NATIONWIDE PROPERTY & CASUALTY INSURANCE COMPANY. After reviewing the Court file, reviewing the statutory and case law presented by the parties, having heard argument of counsel, and being otherwise duly advised in the premises, the Court finds as follows:
FINDINGS OF FACT
1. On. December 4, 2003, Plaintiff provided medical care to Bruce Campos for covered injuries Mr. Campos sustained as the result of a motor vehicle accident that occurred on September 15, 2003.
2. For this December 4, 2003 date of service (the “DOS”), it is undisputed that Plaintiff timely sent Defendant its CMS-1500 along with its medical records and other documentation relating to this DOS.
3. It its undisputed that after receiving Plaintiff’s CMS-1500 and the accompanying documentation, Defendant paid $143.08 of the $452 in total charges therein.
4. In order to obtain the balance owed for the subject DOS, Plaintiff filed this action for PIP benefits pursuant to an assignment of benefits from Bruce Campos.
5. In this suit for PIP benefits, Defendant requests this Court grant its Motion for Summary Judgment because the Plaintiff medical provider failed to include its medical license number in Box 31 of the CMS-1500 form.
6. On the CMS-1500 provided to Defendant for the subject DOS, Plaintiff’s medical license number is clearly and legibly printed in Box 33 of the CMS-1500.
7. Florida Statutes, Section 627.736(5)(b)(1) (2003) states that:
An insurer or insured is not required to pay a claim or charges:
a. Made by a broker or by a person making a claim on behalf of a broker;
b. For any service or treatment that was not lawful at the time rendered;
c. To any person who knowingly submits a false or misleading statement relating to the claim or charges;
d. With respect to a bill or statement that does not substantially meet the applicable requirements of paragraph (d);
8. Florida Statutes, Section 627.736(5)(d) (2003) states that:
All statements and bills for medical services rendered by any physician, hospital, clinic, or other person or institution shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid Services (CMS) 1500 form, UB 92 forms, or any other standard form approved by the office or adopted by the commission for purposes of this paragraph. All billings for such services rendered by providers shall, to the extent applicable, follow the Physicians’ Current Procedural Terminology (CPT) or Healthcare Correct Procedural Coding System (HCPCS), or ICD-9 in effect for the year in which services are rendered and comply with the Centers for Medicare and Medicaid Services (CMS) 1500 form instructions and the American Medical Association Current Procedural Terminology (CPT) Editorial Panel and Healthcare Correct Procedural Coding System (HCPCS). 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.” In determining compliance with applicable CPT and HCPCS coding, guidance shall be provided by the Physicians’ Current Procedural Terminology (CPT) or the Healthcare Correct Procedural Coding System (HCPCS) in effect for the year in which services were rendered, the Office of the Inspector General (OIG), Physicians Compliance Guidelines, and other authoritative treatises designated by rule by the Agency for Health Care Administration. No statement of medical services may include charges for medical services of a person or entity that performed such services without possessing the valid licenses required to perform such services. For purposes of paragraph (4)(b), an insurer shall not be considered to have been furnished with notice of the amount of covered loss or medical bills due unless the statements or bills comply with this paragraph, and unless the statements or bills are properly completed in their entirety as to all material provisions, with all relevant information being provided therein.
9. I find that the CMS-1500 provided to Defendant for the subject DOS did substantially meet the applicable requirements of Florida Statutes, Section 627.736(5) (2003).
It is, therefore, ORDERED AND ADJUDGED that:
1. Defendant’s Motion for Summary Judgment is DENIED.
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