15 Fla. L. Weekly Supp. 940b

Insurance — Personal injury protection — Notice of loss — HCFA form — Professional license number — Insurer has not been placed on notice of covered loss where HCFA forms submitted did not include professional license number of medical provider/diagnostic testing facility, notwithstanding argument that diagnostic testing facilities are not required to hold license

WIDE OPEN MRI, INC., a/a/o CARLOS CALLE, Plaintiff, vs. UNITED AUTOMOBILE INSURANCE CO., a Florida corporation, Defendant. County Court, 17th Judicial Circuit in and for Broward County, Civil Division. Case No. 05-16912 COCE 49. August 6, 2007. Lee J. Seidman, Judge. Counsel: Michael Brodi, for Plaintiff. Jairo Lanao, for Defendant.

ORDER GRANTING DEFENDANT’S MOTION FOR FINAL SUMMARY JUDGMENT

THIS CAUSE, having come before the Court upon Defendant’s Final Motion for Summary Judgment on Box 31. The Court having heard argument of counsel, reviewed the court file and considered the applicable law, and it is therefore,

ORDERED AND ADJUDGED as follows:

I. FINDINGS OF FACT

1. This is an action for damages to recover no-fault benefits pursuant to Florida Statutes § 627.736.

2. On or about September 22, 2004, Carlos Calle was involved in an automobile accident and suffered injuries.

3. As a result, Carlos Calle, sought medical treatment and services at Wide Open MRI for those personal injuries.

4. The Plaintiff submitted two HCFA forms seeking payment; however, the forms did not include the professional license number of the provider as required by Florida Statutes §627.736(5)(d) (2003) in Box 31.

5. As an affirmative defense, the Insurer alleged that it did not receive notice of a covered loss pursuant to Florida Statutes §627.736(4)(b) (2003).

6. Defendant filed its Motion for Summary Judgment concerning its affirmative defense identified in paragraph 5 above.

II. CONCLUSIONS OF LAW

SUMMARY JUDGMENT STANDARD

7. It is established law in Florida that on a Motion for Summary Judgment, the moving party bears the burden of proving the non-existence of a genuine issue of material fact. Holl v. Talcott, 191 So. 2d 40 (Fla. 1966).

8. Once the moving party has met its burden, the burden shifts to the non-moving party to present competent evidence demonstrating the existence of a genuine issue of material fact. Id. at 43.

BOX 31

9. The Defendant filed a Motion for Summary Judgment on the grounds that it has not been placed on notice of a covered loss or medical bills due as the HCFA forms in question submitted by the Plaintiff do not contain any mention of the professional license number of the person rendering the medical service and, thus, does not comply with requirements of Florida Statutes §627.736(5)(d) (2003) as it relates to §627.736(4)(a) and (b) (2003).

10. In support of its Motion, the Defendant filed the HCFA forms for two dates of service on which the diagnostic tests of the magnetic resonance imagings were allegedly performed.

11. The Plaintiff at no time contested the fact that the HCFA (CMS 1500) forms in question for such services do not contain the required professional licenses of the person or persons who rendered said services in Box 31.

12. It is equally undisputed that the HCFA forms do not contain the professional license numbers of the provider in Box 31 or anywhere on said forms.

13. The Defendant, as the moving party, has met its burden to demonstrate the non-existence of a genuine issue of material fact.

14. The burden has then shifted to the Plaintiff to demonstrate by competent evidence the existence of an issue of material fact.

15. The Plaintiff did not file any competent evidence in support of its position.

16. The Plaintiff argued that since the services in question were for diagnostic testing, such professional license numbers on the HCFA forms are not required because the diagnostic testing facilities such as the Plaintiff are not required by Florida law to hold any license for said services.

17. The Defendant argued that under a strict reading of the statute, it is required to have the professional license numbers as it was introduced in the law under the 2003 Amendment to the PIP statute and under the aforementioned sections of the law 4(a) and (b) and 5(d), dictate the requirements for proper bill submission and notification requirements.

18. Defendant accordingly, argued that no payment is overdue in the case since the Defendant, for purposes of a notice of a covered loss, cannot be considered to have been furnished with notice of the amount of a covered loss where the HCFA (CMS-1500) forms were incomplete.

19. The Defendant relied on Elias Garcia v. United Automobile Insurance Company, 12 Fla. L. Weekly Supp. 888b (17th Cir. Ct. 2005); Aries Ins. Co. v. First Chiropractic Clinic, Inc., 12 Fla. L. Weekly Supp. 637 (13th Cir. Ct. 2005); Top Chiropractic v. Nationwide Mutual Insurance Co., 12 Fla. L. Weekly Supp. 152 (9th Cir. Ct. 2004); Finlay Diagnostic Center a/a/o Manuel Alcoser v. Progessive American Insurance Company, 13 Fla. L. Weekly Supp. 610 (2006) and Hope Health Wellness a/a/o Michelle Henderson v. Geico General Insurance Company.

20. Florida Statute sections 627.736(4)(a) and (b) set forth the timetable for accrual of these benefits:

Benefits due from an insurer under ss. 627.730-627.7405 shall be primary, except that benefits received under any 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 issued under ss. 627.730-627.7405. . . .

(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 ss. 627.730-627.7405.

(b) Personal injury protection insurance benefits paid pursuant to this section 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 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 to the insurer. However, any payment shall not be deemed overdue when the insurer has reasonable proof to establish that the insurer is not responsible for the payment, notwithstanding the fact that written notice has been furnished to the insurer.

21. Furthermore, Florida Statute section 627.736(5)(d) states:

(d) 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.

22. The Court makes a literal inquiry of the pertinent sections of the statute to determine whether a professional license number is required under the statute and, under strict construction of the law, considers that as a matter of law, the language of such statute, mandates that a professional license number be included on the HCFA forms.

23. That the Defendant, as a matter of law, has not been placed on notice of a covered loss pursuant to Florida Statutes § 627.736(5)(d) (2003) and in accordance with (4)(a) and (b).

IT IS THEREFORE ORDERED and ADJUDGED that Defendant’s Motion is hereby GRANTED.

The Plaintiff, WIDE OPEN MRI, INC., a/a/o Carlos Calle, shall take nothing by this action and Defendant, United Automobile Insurance Company, shall go hence without day.

The Court reserves jurisdiction to entertain a Motion for attorney’s fees and costs by Defendant.