Carrier Response To Petition For Resolution Of Reimbursement Dispute {DFS Form 3160-0024}

DFS-F6-DWC-3160-0024 - CARRIER RESPONSE TO PETITION FOR RESOLUTION OF REIMBURSEMENT DISPUTE FORM. This Florida Department of Financial Services (DFS) form is used by workers’ compensation insurance carriers to formally respond to a Petition for Resolution of Reimbursement Dispute. Carriers must file the completed form with DFS within 30 days of receiving the petition, as required under Rule 69L-31.004, Florida Administrative Code. The response must include the carrier’s asserted reimbursement amount, supporting documentation, copies of any disallowance or adjustment notices, and proof of service to the petitioner. Additional disclosures may involve contract documentation, denial forms (EOBR Codes 10 or 11), and requests for supporting medical records. The form also requires confirmation of whether the petitioner was authorized to treat the injured worker on the dates in dispute. www.FormsWorkflow.com