16 Fla. L. Weekly Supp. 193a
Online Reference: FLWSUPP 162MABRY
Insurance — Personal injury protection — Notice of loss — Claim form — Where medical provider mistakenly indicated on CMS 1500 claim forms that treatment was not related to automobile accident, claim forms were not complete as to material provisions, and insurer was not provided with notice of covered loss — No merit to argument that insurer was provided with notice of loss despite error because medical reports attached to claim forms referred to automobile accident — Later submission of corrected claim forms did not provide notice of loss where corrected claim forms were not provided within 35 days of dates of service
SOUTH FLORIDA CHIROPRACTIC REHAB, INC., D/B/A BOCA SPINE & WELLNESS CENTER, INC., a Florida Corporation, (Elizabeth K. Mabry), Plaintiff, v. UNITED SERVICES AUTOMOBILE ASSOCIATION, a Florida Corporation, Defendant. County Court, 15th Judicial Circuit in and for Palm Beach County, Civil Division. Case No. 502007SC012036XXXXSB (RD). November 4, 2008. Donald W. Hafele, Judge. Counsel: Steven K. Platzek. Miriam R. Merlo, Gaebe, Mullen, Antonelli, Esco & DiMatteo, Coral Gables, for Defendant.
ORDER AND FINAL JUDGMENT GRANTING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT
This case was considered on September 29, 2008, on the Motion of Defendant, UNITED SERVICES AUTOMOBILE ASSOCIATION, for Summary Judgment, and after hearing argument of counsel, reviewing the pleadings and record presented, and otherwise being fully advised in the premises, the Court finds as follows:
Background:
1. The Plaintiff, a medical provider pursuant to an assignment of benefits, filed this action for PIP benefits resulting from an automobile accident that occurred on March 30, 2007. Plaintiff is a chiropractic facility that administered treatment to Elizabeth K. Mabry. At the time of the automobile accident, Ms. Mabry was insured by an automobile policy issued by the Defendant which provided for payment of personal injury protection (PIP) benefits.
2. At issue are the bills submitted by the Plaintiff on CMS-1500 forms for dates of services rendered which included April 5, 2007, April 11, 2007, May 10, 2007, June 6, 2007 and June 12, 2007.
3. It is undisputed that at the time these bills were originally submitted, the Plaintiff had indicated in Box 10(b) of the CMS 1500 Forms that the treatment was not related to an automobile accident. It is also undisputed that the Defendant timely advised the Plaintiff with an Explanation of Reimbursement form that “Box 10, question B of the CMS 1500/HCFA form indicates the medical treatment rendered is not related to an auto accident. Services not related to an auto accident are not reimbursable.”
4. Subsequent to Defendant providing the Plaintiff with the Explanation of Reimbursement as to the Box 10 deficiency and the fact that the bills were not payable because the services were not related to an auto accident, the Plaintiff submitted corrected bills with Box 10 marked as being related to an auto accident. These corrected bills also included additional bills with additional dates of service. It is undisputed that the corrected bills were not submitted within the thirty-five (35) days from the date of service. It is also undisputed that the additional dates of service with Box 10 properly completed were timely and were paid by the Defendant.
5. Counsel for Plaintiff argued that it substantially complied with the completion of the CMS 1500 forms because the medical records submitted with the original bills referred to the automobile accident and injuries resulting therefrom and further, that the date of onset of illness, injury or pregnancy in Box 14 matched up with the date of accident. Plaintiff also argued that there is no statutory requirement that Box 10 needs to be checked at all and that the only requirement is that the services are reasonable, related and necessary and that the insurer receive notice of a covered loss.
Court’s Analysis:
The Court disagrees with the Plaintiff’s argument. The suggestion that a number of HCFA forms, submitted with an “X” in the Box marked “NO” in response to whether or not the loss was sustained from an automobile accident and expecting that, despite that language in the HCFA form, the insurer then has to utilize some type of collateral paper, such as medical records, to do the work that the provider in this self-enacting form-based process should have done, appears as illogical to me as it did to Judge Emas in his analysis on a different, yet similar issue in Coral Imaging Services, a/o/a Virgilio Reyes v. Geico Indemnity Ins. Co., 955 So.2d 11 (Fla. 3d DCA 2006). As that Court stated, citing to Warren v. State Farm Mutual Auto Ins. Co., 899 So.2d 1090 (Fla. 2005):
It is apparent by the plain language that the intent of the statutory provision at issue was to impose statutory time limits on the submission of medical bills in a no-fault scheme rather than adherence to the statute of limitations period provided for court actions for breach of contract . . . .
Although the Supreme Court in Warren was not faced with the question of an insurer’s authority to pay a bill that violates the time and billing requirements of Section 627.736(5)(b), it is instructive that the Court used the above language in describing the mandatory nature of the time requirements before a provider can receive payment. An interpretation of a statute by the highest court of a state is generally regarded as an integral part of the statute. . Seddon v. Harpster, 369 So.2d 662 (Fla. 2d DCA 1979).
While the issue in the cases above do not deal with the particular provision in this matter, it is instructive in our analysis of the issues presented herein. The Court finds that the opinions in Coral Imaging Services, a/o/a Virgilio Reyes v. Geico Indemnity Ins. Co., 955 So.2d 11 (Fla. 3d DCA 2006) and Warren v. State Farm Mutual Auto Ins. Co., 899 So.2d 1090 (Fla. 2005) stand for the proposition that a properly completed HCFA form is necessary for the orderly and timely payment of PIP benefits by an insurer to its insured or a provider. The term “properly completed” has been defined in Fla. Stat. Section 627.732(13) as:
. . .providing truthful, substantially complete, and substantially accurate responses 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.
Fla. Stat. Section 627.736(5)(d) requires that:
All statements and bills for medical services rendered by any physician, hospital, clinic, or other person shall be submitted to the insurer on a properly completed Centers for Medicare and Medicaid (CMS 1500) form . . . . . 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.
Because the Plaintiff is making a claim for payment of PIP benefits which are by definition benefits due as a result of an automobile accident, whether or not Box 10 of the CMS 1500 form (i.e., the HCFA form) is marked “YES” or “NO” to the question if the services are related to an automobile accident is certainly relevant to the claim being presented and thus, necessarily a material provision of the CMS1500/HCFA form. Plaintiff’s argument that the forms were later corrected to indicate “YES” in Box 10 still fails to provide notice of a covered loss to the insurer because as noted by the Florida Supreme Court in the Warren case, the time requirements contained with the statute are mandatory and strict adherence to these provisions is necessary in order to effectuate the legislative intent of the statute. It is undisputed that the corrected forms were not provided by the Plaintiff within the thirty-five (35) days required by the statute.
Accordingly, the Court finds that Plaintiff failed to provide notice of a covered loss on the issue of Box 10 and Defendant’s motion for summary judgment on that issue is granted. It is not the insurer’s duty to have to utilize collateral documentation outside of a HCFA form, particularly where, as here under these facts, there are repetitive HCFA forms that indicate that the answer to the question of whether or not the injuries related to an automobile accident are responded to as no and then an untimely explanation is provided outside of the 35-day limitation. Defendant’s motion for summary judgment on the issue of Box 31 is denied based upon substantial compliance by the Plaintiff because the license number was contained in Box 33 and there was no indication from the insurer that it was either confused or otherwise prejudiced by that number being included in Box 33.
Final Summary Judgment is entered in favor of Defendant and against the Plaintiff. The Court reserves jurisdiction to entertain a motion on attorneys fees and costs, if applicable.
