Notes on payer behavior
Workers' comp denied your bill in Florida: read the EOBR code first
A Florida workers' comp carrier doesn't send a remittance. It sends an Explanation of Bill Review, an EOBR, with a two-digit code per line under Rule 69L-7.740. The code tells you whether you're looking at a coding correction, a documentation request, an authorization fight, or a silent-PPO discount. Read it before anything else, because the route for each is different and the clock on all of them is 45 days.
The EOBR codes that matter
| Code | What the carrier is saying | What to do |
|---|---|---|
| 10 / 11 | Denied, compensability or the claim itself | Usually the adjuster's call on the injury. Confirm the claim is accepted before spending time. |
| 23 | Diagnosis doesn't support the service | Check the accepted body part and diagnosis on the claim. Often a coding fix, sometimes a fight. |
| 24 | Service not appropriate | Read it as medical necessity. Answer with the record and the treatment guideline. |
| 30 | No authorization | Pull the authorization request and the carrier's response date. The three-day rule below may decide it. |
| 40 / 41 | Documentation missing or insufficient | Send exactly what's named, with the bill number, inside the window. |
| 62 | Coding | Corrected bill. |
| 63 | Bundled | Check the state reimbursement manual's own rules first. Carriers may use NCCI edits only where the manual doesn't say otherwise. |
| 80 / 81 | Adjusted to the fee schedule or a contract | Recompute against the 2025 rates: 175 percent of Medicare for physician services, 210 percent for surgical. The rate note. |
| 93 | Paid per contract; network name required | The silent-PPO detector. If you never signed with the named network, the discount is disputable. |
The three-day rule
Under section 440.13(3)(d), Florida Statutes, a carrier must respond to an authorization request by the close of the third business day, and a carrier that fails to respond to a written request for authorization for referral for medical treatment in that time "consents to the medical necessity for such treatment." For specialist consultations, surgery, therapy, X-rays, and special diagnostic tests costing more than $1,000, section 440.13(3)(i) requires express authorization unless the carrier fails to respond within ten days to a written request, and approval of a treatment plan is not express authorization. That rule reverses a large share of code-30 denials on its own, provided you can show the written request and the date it was sent. Keep the fax confirmation or portal receipt on every authorization request as a matter of habit. The rule does nothing for you without it. The statute text, quoted, in the handbook.
Which denials are worth a petition
Florida doesn't route workers' comp payment disputes through the carrier's appeal process. There is one regime for every carrier and TPA: a petition to the Department of Financial Services under section 440.13(7), within 45 days of receiving the EOBR. Worth filing: code 30 with a three-day-rule violation, code 80 or 81 below the fee schedule, code 63 where the state schedule doesn't bundle, code 93 with no contract, and documentation denials where you sent the documents. Not worth filing: compensability denials, which belong to the injured worker's attorney, and coding errors you can fix with a corrected bill.
The lever inside the petition is the 30-day response rule. Once you file, the carrier has 30 days to respond with substantiating documentation or it waives all objections. Carriers that show a pattern or practice of improper denials face repayment, penalties of up to $5,000 per instance, and the provider's attorney fees. The petition mechanics and the 45-day clock, in detail.
The traps that get petitions dismissed
- Certified mail only. The copy served on the carrier must go by USPS certified mail; FedEx, UPS, fax, and email don't count even if the carrier confirms receipt. The petition itself reaches DFS by mail, common carrier, or hand delivery. There's no electronic filing route in Rule 69L-31.
- Twenty days to cure. An incomplete petition gets a deficiency notice; miss the cure window and it's dismissed with prejudice. Attach everything the first time.
- The clock doesn't stop. Carrier audits and independent medical examinations don't toll the 45 days.
- The carrier is accountable regardless of its vendors. The state's own reimbursement manual says so. A bill-review company's error is the carrier's error.
Why this matters more than it used to
Florida raised physician reimbursement to 175 percent of Medicare and surgical to 210 percent effective January 2025. Carriers absorbed a cost increase and the bill-review vendors that price their claims earn on what they cut. Our full-year audit of an orthopedic practice in Miami found the workers' comp bill-review shops with addressable amounts exceeding what they had paid. The EOBR is where that shows up, one code at a time.
Questions people ask
What is an EOBR in Florida workers' comp?
The Explanation of Bill Review, the carrier's line-by-line statement of how it paid, reduced, or denied a medical bill, with two-digit reason codes defined in Rule 69L-7.740.
How long do I have to dispute a workers' comp denial in Florida?
Forty-five days from receipt of the EOBR, by petition to the Department of Financial Services under section 440.13(7). Carrier appeal processes don't apply.
What is the three-day rule in Florida workers' comp?
A carrier that fails to respond to a written authorization request within three business days is deemed to consent to the medical necessity of the treatment. Specialist consultations, surgery, therapy, X-rays, and special diagnostic tests over $1,000 need express authorization unless the carrier fails to respond within ten days to a written request.