DEPARTMENT OF EDUCATION BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES FOR CARRIER’S DATE STAMP SENT TO DEPARTMENT 2728 CENTERVIEW DRIVE, 101A FORREST BUILDING TALLAHASSEE, FLORIDA 32399-0400 REEMPLOYMENT SERVICES BILLING FORM 1. NAME 2. SOCIAL SECURITY NUMBER 4. DATE OF REFERRAL 5. TELEPHONE NUMBER ( 6. A) CARRIER/TPA ADDRESS 3. DATE OF ACCIDENT (MM/DD/YY) ) 7. A) REMIT TO: B) ADDRESS C) CITY D) ST. E) ZIP CODE F) TELEPHONE NUMBER. B) ZIP CODE ( C) SC/TPA CODE: FEIN#: D) CARRIER CODE E) CONTACT NAME F) TELEPHONE NUMBER ) FEIN# G) PROVIDER FEIN: ( 8. BILLING DATE (MM/DD/YY) 9. PROVIDER STATUS INDEPENDENT ) FACILITY / COMPANY G) CONTACT EMAIL 10. A) PROVIDER NAME 10. B) PROVIDER NUMBER 11. A) FACILITY/COMPANY NAME 11. B) FACILITY/COMPANY NUMBER 12. RETURN TO WORK DATE 13. STARTING WEEKLY WAGE BILLING INFORMATION 14. DATE OF SERVICE 15. REEMPLOYMENT SERVICE A) CODE 20. DATE RECEIVED B) DESCRIPTION 16. UNITS OF SERVICE 18. TOTAL BILLED 19. AMOUNT REIMBURSED 22. 21. DATE REIMBURSED 17. CHARGE PER UNIT 23. TOTALS Form DWC-21, Rev. American LegalNet, Inc. www.USCourtForms.com DWC-21 Department of Education Reemployment Services Billing Form. I. GENERAL INSTRUCTIONS AND INFORMATION Services provided pursuant to s. 440.491, F.S., and 6A-22, F.A.C. shall be reported, billed and submitted to the carrier on form DWC-21, Department of Education Reemployment Services Billing Form, unless those services are provided by a hospital licensed under Chapter 395, F.S., a managed care arrangement pursuant to s. 440.134, F.S., or a health care provider who provides services pursuant to s. 440.13, F.S. Reimbursement to a rehabilitation facility shall be only for the specific program for which the facility is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). In order for reimbursement to be made, the qualified rehabilitation provider shall enter the 3-digit service code followed by the service code description, both on the same line. II. FORM COMPLETION Complete Items 1-23 of form DWC-21 on the initial, interim and final billing as follows: Item 1: Injured Employee’s Name: Enter the injured employee's name in first name, middle name, last name order. Item 2: Social Security Number: Enter the injured employee's Social Security Number. If no Social Security Number, enter the number from the Arrival and Departure Card (Form I-94) or the Alien Registration Receipt Card (Form I-151). Item 3: Date of Accident: Enter the date of the injured employee's accident in MM/DD/YY format. Item 4: Date of Referral: Enter the date of the carrier or Department referral for reemployment services in MM/DD/ YYYY format. Item 5: Telephone number: Enter the injured employee's home telephone number, including area code. Item 6: Carrier/TPA information: Enter the complete mailing address including the zip code plus four digits for the carrier or service company/TPA, and enter the Division of Workers’ Compensation’s assigned 5 digit code and Federal Employer Identification Number (FEIN) for the carrier and, if applicable, the service company/ TPA. Additionally, include the carrier / TPA contact name, telephone number and E-mail address. Item 7:Remit To: Enter name, complete mailing address, telephone number and Federal Employer Identification Number (FEIN) of the qualified rehabilitation provider, company or facility to whom payment is to be made. The carrier shall have the FEIN number before payment can be made. Item 8: Billing Date: Enter the date of this billing using MM/DD/ YYYY format. Item 9: Provider Status: Check appropriate box. Item 10: Provider Name and Provider Number: Enter the name and Department assigned provider number of the qualified rehabilitation provider or facility vocational specialist responsible for the services provided. Enter "ZZ9999999" for the provider number if the services were provided out of state. Item 11: Facility/Company Name and Facility/Company Number: Enter the name and Department assigned facility, company or agency number for the facility, company or agency which employs the qualified rehabilitation provider. Enter "ZZ9999999" for the provider number if the services were provided out of state. Item 12: Return to Work Date: Enter the date the injured employee returned to work as the result of reemployment services using MM/DD/YYYY format. Enter only on final billing form. American LegalNet, Inc. www.USCourtForms.com Item 13: Starting Weekly Wage: Enter the injured employee's starting weekly wage if he/she has returned to work after receiving reemployment services. Item 14: Date of Service: Enter the date reemployment services were provided using MM/DD/YYYY format. Item 15: Reemployment Service Code and Description: Enter the service code and service code description which most accurately reflects the services provided. Item 16: Units of Service: Enter the total units of service using tenths of an hour (e.g., 0.1 equals six minutes and 1.0 equals 60 minutes). Item 17: Charge per Unit: Enter the charge per unit of service. Item 18: Total Billed: The total dollar amount billed by the provider to the carrier for the services provided. Item 19: Amount Reimbursed: For carrier only. Enter amount reimbursed per code this billing; may leave blank if amount reimbursed is same as amount charged. Item 20: Date Received: For carrier only. Enter the date the carrier received Form DWC-21 for payment from qualified rehabilitation provider, facility or company using MM/DD/YYYY format. Item 21: Date Reimbursed: For carrier only. Enter the date carrier issued check for services reported and billed on Form DWC-21 using MM/DD/YYYY format. Item 22: Total Charge: Enter total of all charges this billing. Item 23: Total Reimbursed: For carrier only. Enter the total amount actually reimbursed. SECTION III. SERVICE CODES AND DESCRIPTIONS The following service codes and descriptors may be used on the Form DWC-21. MCCMedical Care Coordination – includes, but is not limited to, coordinating physical rehabilitation services such as medical, psychiatric, or therapeutic treatment for the injured employee, providing health training to the employee and family, and monitoring the employee’s recovery. The purposes of medical care coordination are to minimize the disability and recovery period without jeopardizing medical stability, to assure that proper medical treatment and other restorative services are timely provided in a logical sequence, and t o contain medical costs [ss 440.491, (1)(b), F.S.]. RESReemployment Services – means services that include, but are not limited to, vocational counseling, jobseeking skills training, ergonomic job analysis, transferable skills analysis, selective job placement, labor market surveys, and arranging other services such as education or training, vocational and on-thejob, which may be needed by the employee to secure suitable gainful employment [ss 440.491, (1)(e), F.S.]. REAReemployment Assessment – means a written assessment performed by a qualified rehabilitation provider which provides a comprehensive review of the medical diagnosis, treatment, and prognosis; includes conferences with the employer, physician, and claimant; and recommends a cost-effective physical and vocational rehabilitation plan to assist the employee in returning to suitable gainful employment [ss 440.491, (1)(d), F.S.]. VEV Vocational Evaluation – means a review of the employee’s physical and intellectual capabilities, his aptitudes and achievements, and his work-related behaviors to identify the most cost-effective means toward his return to suitable gainful employment [ss 440.491 (1)(h), F.S.]. May be used only on cases receiving a vocational evaluation under 440.491(6). MRRMedical Records Review/Nursing Assessment - An assessment of available information to determine whether the active efforts toward returning the injured employee to long-term, full-time employment are warranted at the current time and, if not, identification of issues interfering with reemployment and an action plan to resolve the issues. For use with Department sponsored services only. American LegalNet, Inc. www.USCourtForms.com