15 Fla. L. Weekly Supp. 495a
Insurance — Personal injury protection — Notice of loss — Claim form — License number — Medical provider billing globally for professional and technical component of MRI was required to disclose professional license number of person performing service in box 31 of CMS 1500 form, not merely healthcare facility license number — Summary judgment entered in favor of insurer
OAKLAND PARK MRI, INC., Rosa Rodriguez, Plaintiff, v. UNITED SERVICES AUTOMOBILE ASSOCIATION, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 07-03021 COCE 56. March 10, 2008. Linda R. Pratt, Judge. Counsel: Charles J. Kane. Miriam R. Merlo, Gaebe, Mullen, Antonelli, Esco & Dimatteo, Coral Gables, for Defendant.
FINAL SUMMARY JUDGMENT IN FAVOR OF DEFENDANT
THIS CAUSE was considered on January 29, 2008 on the Motions of Defendant and Plaintiff for Summary Judgment. Based upon the pleadings and materials filed, evidence presented and argument of counsel, the Court makes the following findings:
1. Plaintiff is a medical provider who provided MRI services to Defendant’s insured, Rosa Rodriguez, on May 12, 2006, resulting from an automobile accident.
2. Defendant is the PIP insurer for Rosa Rodriguez and provided PIP benefits to Rosa Rodriguez on May 12, 2006 for the automobile accident which occurred on March 26, 2006.
3. Plaintiff billed Defendant on a CMS 1500 form for services rendered on May 12, 2006 to Ms. Rodriguez. The amount billed was $1,484.36 and was billed globally for both components, i.e., the professional and technical component of the MRI services provided to Ms. Rodriguez.
4. Plaintiff included a healthcare facility license number (HCC #) in Box 31 of the CMS 1500 form. It is Defendant’s position that the facility license number was incorrect.
5. Plaintiff filed a Motion for Summary Judgment and argued that the only license number that the Plaintiff is required to have is the healthcare clinic license number but that there is not a requirement to put that license or any other license number in Box 31. The record shows that the representative of the Plaintiff testified at deposition that the facility license number is the number required to be placed in Box 31.
6. Defendant argued that because the Plaintiff is billing globally for a professional and technical component, it is required to include the professional license number in Box 31. Alternatively, Defendant argued that should the Court find that the facility license number, i.e., the healthcare clinic license number meets the requirement for the number required in Box 31, that the number provided by the Plaintiff was invalid, based upon an affidavit of Roger Bell from ACHA.
7. Defendant further argued that because Fla. Stat. Section 627.736(5)(d) requires that “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. . .” that the legislature specifically carved out an exception for hospitals and not for the provider of MRI services. Defendant further argued that the Senate Staff Analysis for Fla. Stat. Section 627.736(5)(d) compared the new requirement for the licensing information to the existing requirement for Medicare, which required that a provider include “his/her” license number on the form under Box 31, and that such requirement only goes to an individual professional provider because it used the word “his/her” as opposed to “its”.
8. Finally, Defendant argued the remaining section of § 627.736(5)(d), Fla. Stat. which provides that:
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.
Defendant further explained that Fla. Stat. Section 627.732(13) defined the term “properly completed” as:
‘Properly completed’ means providing truthful, substantially complete, and substantially accurate responses as to all material elements to each applicable request for information or statement by a means that may lawfully be provided and that complies with this section, or as agreed by the parties.
Defendant argued that if a medical provider does not include any license number or fills in the incorrect facility license number, then the medical provider has not “properly completed” the statement or bill as required by the statute and the insurer has not been placed on notice of a covered loss.
Accordingly, the Court finds that if the medical provider is billing for the professional component, it needs to disclose the professional license number of the person performing the service. Because the Plaintiff failed to include a professional license number in Box 31 where the provider billed globally for an MRI, Defendant has not been placed on notice of a covered loss. The Court does not reach Defendant’s second argument as to the incorrect healthcare (facility) license number as the issue is moot. Plaintiff’s Motion for Summary Judgment is Denied. Summary Judgment is entered in favor of Defendant, UNITED SERVICES AUTOMOBILE ASSOCIATION and against the Plaintiff, OAKLAND PARK MRI, Inc.
The Court reserves jurisdiction for the entry of attorney fees and costs, if appropriate.
