17 Fla. L. Weekly Supp. 394a
Online Reference: FLWSUPP 1705WHITInsurance — Personal injury protection — Delay in payment — Request for information or documentation — Request in explanation of benefits for specific description of non-specific CPT code did not toll time for payment of benefits where claim form submitted to insurer lists description of code as “cervical pillow”
FIDEL S. GOLDSON, D.C., P.A., a Florida Corporation (assignee of White, Tanya), Plaintiff, v. STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Defendant. County Court, 17th Judicial Circuit in and for Broward County. Case No. 08-03598 COCE (53). March 8, 2010. Robert W. Lee, Judge. Counsel: Law Office of Russel Lazega, North Miami. Conroy, Simberg, Ganon, et al., P.A., Hollywood.
ORDER GRANTING PLAINTIFF’ S MOTION FOR PARTIAL SUMMARY JUDGMENT
THIS CAUSE, came before the court for hearing on February 17, 2010 on the Plaintiff’s Motion for Partial Summary Judgment as to Defendant’s Second Affirmative Defense (Additional Information Requested), and the court, having reviewed the Motion, the court file, legal authorities and having heard argument of counsel, finds as follows:
Factual Background: This is a P.I.P. suit. The Plaintiff billed and the Defendant denied the following CPT codes for payment (which are the only remaining CPT Codes at issue): 95832 billed on 9/8/07 in the amount of $175.00; 95832 billed on 10/16/07 in the amount of $175.00; and 99070 billed on 3/21/08 in the amount of $60.00. Defendant has asserted a defense to payment of CPT code 99070 (which is a supply charge for a cervical pillow). The defense alleges that CPT code 99070 is a non-specific code that requires a description of the procedure to accompany the bill; that Defendant requested additional information in order for it to be able make a reimbursement decision; and that the Plaintiff failed to respond to the request. Plaintiff moves for partial summary judgment as to the Defendant’s defense asserting that Defendant had all necessary information available to process the claim as Plaintiff’s Health Insurance Claim Form (hereafter “HCFA”) listed the description of CPT code 99070 (“cervical pillow”) conspicuously next to the code.
Conclusions of Law: This court finds that the Defendant’s explanation of review (hereafter “EOR”) did not request any additional information other than what was already provided by the Plaintiff.
Specifically, the explanation for denial of CPT code 99070 provided in Defendant’s EOR states:
This CPT/HCPCS code is a non-specific code. As noted in CPT/HCPCS a description of this procedure must accompany the bill for proper consideration of payment and for verification of proper coding.
The bottom of the EOR further states:
Pursuant to Florida Statute 627.736(6)(b), should you have any information to substantiate payment of an additional amount for the services rendered, please forward for consideration.
The Plaintiff’s HCFA for code 99070 submitted to Defendant lists the description of CPT code 99070 (“cervical pillow”) conspicuously next to the code, therefore, the Defendant’s request for additional information under Florida Statute 627.736(6)(b) did not serve to toll the time for payment of the code.
Accordingly, it is hereby:
ORDERED AND ADJUDGED that Plaintiff’s Motion for Partial Summary Judgment is GRANTED.
