Current through Reg. 50, No. 187; September 24, 2024
(1) General
Provisions. All insurers offering a managed care arrangement for the provision
of health services for the treatment of persons filing workers' compensation
claims shall obtain an authorization from the agency in accordance with the
following procedures:
(a) Applications for an
initial authorization, amendment of the authorized plan of operation, or
renewal shall be submitted with the following:
1. A completed copy of AHCA Form 3160-0004,
November 2000, incorporated by reference herein;
2. Required attachments as specified in AHCA
Form 3160-0004, November 2000; and,
3. Written agreements linking the entities
within the managed care arrangement and specifying the duties of each entity.
Application forms are available from and shall be submitted
to the Agency for Health Care Administration, Division of Managed Care and
Health Quality, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop #45,
Tallahassee, Florida 32308.
(b) An initial application for authorization
shall be submitted to the agency at least 90 days prior to the intended date of
implementation of services. An amendment application shall be submitted to the
agency 60 days prior to the effective date of the proposed change in the plan
of operation. Upon receipt of the application the agency shall review the
content to determine compliance with the requirements of sections
440.134(5)-(15),
F.S.
(c) The agency shall notify
applicants for initial or renewal authorization in writing via certified mail
of any deficiencies in the application within 30 days of the receipt of the
application. The applicant shall provide information necessary to complete the
application within 30 days of receipt of the written notice. Failure to timely
submit the necessary information shall result in denial of the application
unless the applicant needs an extension of time due to circumstances beyond its
control and requests the extension within 30 days of its receipt of the written
notice of deficiencies. No extensions shall exceed 90 days or the expiration
date of the workers' compensation managed care arrangement.
(d) The agency shall provide notice to the
applicant of its right to administrative review under sections
120.569 and
120.57, F.S., with its written
notice of intent to deny an application.
(e) Applications to amend an approved plan of
operation by replacing the delegated managed care organization or provider
network shall address the continuity of care and coordination of medical
services for injured employees during the transition. The applicant shall
submit information that identifies the activities to be conducted, persons
involved, and dates for completion of the following tasks:
1. The identification and authorization of
out of network services for injured employees whose current primary treating
physician is not in the new provider network and who prefer to continue with
their current provider;
2. The
transfer of injured employees' current medical care management information to
the newly contracted entity; and,
3. The notification of employers and
employees of the requirements of the new network arrangements and the contact
persons via the educational materials required under sections
440.134(14)(a)-(d),
F.S.
(f) Examination. The
agency shall conduct an on-site survey of the managed care arrangement, within
the first year of operation and no less than every two years thereafter, to
determine compliance with the requirements of section
440.134, F.S. The agency shall
verify through subsequent survey that any deficiency identified during a
previous survey is corrected. The agency may verify the correction without
on-site resurvey if written documentation has been received from the insurer or
delegated entity and is accepted by the agency. The agency shall also
investigate on-site any alleged pattern of non-compliance with the requirements
of Section 440.134,
F.S.
(2) Fees. All
initial and renewal applications for authorization of a workers' compensation
managed care arrangement shall be accompanied by a fee of $1, 000 made payable
to the agency. Applications to amend an existing authorized workers'
compensation managed care arrangement do not require submission of a
fee.
(3) Authorization for a
workers' compensation managed care arrangement shall not be sold, assigned, or
otherwise transferred either voluntarily or involuntarily and is valid only for
the legal entity to which it was originally issued.
(4) Validity. Each authorization shall be
valid for a period of two years only for:
(a)
The entity to which it is issued as specified on the authorization letter; and,
(b) The service area approved by
the agency.
(5) Service
areas. Each application shall indicate the geographic service area or areas in
which the insurer or delegated entity will provide managed care services. The
insurer shall offer a managed care arrangement only to those employers whose
place of business or business operations are located in a service area approved
by the agency to provide services under a workers' compensation managed care
arrangement. A service area shall be approved if there is a sufficient number
and type of providers adequate to meet the needs of the geographic area in
addition to other requirements specified under rules
59A-23.003,
59A-23.004,
59A-23.005 and
59A-23.006, F.A.C.
(6) Travel Times. Each application shall
provide information which indicates the ability of the insurer or delegated
entity to provide geographic access to health services for injured employees.
Average travel time for injured employees from the employee's usual employment
site to the nearest primary care delivery site and to the nearest general acute
care hospital in the provider network shall be no longer than 30 minutes under
normal circumstances. Average travel time from the employee's usual employment
site to the nearest provider of specialty physician services, ancillary
services, specialty inpatient hospital services and all other health services
shall be no longer than 60 minutes under normal circumstances.
(7) Provider Network.
(a) Medical services shall be available for
injured employees in the geographic area in which they are employed through
directly or indirectly contracted network(s) of health care providers. The
hours of operation and availability of after-hour care must reflect usual
practices in the community and the insurer must demonstrate that:
1. All medically necessary services are
available and accessible;
2.
Medically necessary referrals are provided within the network or, if
unavailable, outside the network;
3. There are written agreements describing
specific delegated duties for provision of medical services. Delegation of the
provision of medical services by the insurer must be specifically described in
the written agreement linking the insurer with the delegated entity;
4. Written agreements for arrangements in
which the insurer is indirectly linked with a provider network shall contain
language requiring the insurer's approval in advance of a change in the
provider network; and,
5. There are
written agreements with providers prohibiting such providers from billing or
otherwise seeking reimbursement from or recourse against any injured employee
except as specified under section
440.13, F.S.
(b) The insurer or delegated entity, shall
establish and implement a policy and procedure regarding access to services
which reflects usual and customary practices in the community and addresses
access times for emergency, initial, and continuing care including referrals to
specialty services.
(c) The agency
shall examine provider networks at least annually. The insurer or delegated
entity, shall file with the agency an updated list of providers by county, by
specialty, semiannually. The list shall be submitted within six months of the
initial network approval date and every six months thereafter in a format
approved or prescribed by the agency.
(d) The insurer or delegated entity shall
develop and implement a policy and procedure for credentialing and
recredentialing network providers as needed, but at a minimum every two years.
The credentialing criteria shall be specified in the policy and shall include
the core credentialing data specified under section 455.557(2)(d), F.S., and
verification of education of providers as required by section
440.134(8),
F.S.
(e) The recredentialing
process shall monitor and incorporate quality assurance findings and
information on individual providers including sanctions, complaints and
grievances, medical record audits, provider profiling, and employee
satisfaction.
(f) If the insurer
delegates all or part of the credentialing process to other organizations, the
insurer shall specify the activities of the delegated entity and the oversight
and reporting requirements in the written agreement. The insurer shall perform
oversight of the delegated credentialing activities annually.
(g) The insurer or delegated entity shall
designate one or more physicians as a medical care coordinator to manage
medical care for injured workers. A medical care coordinator shall be assigned
for each injured employee. The medical care coordinator shall be licensed under
chapters 458 or 459, F.S., and be board certified by the American Board of
Medical Specialties, or the American Osteopathic Association, or have two years
experience as a participating provider in a workers' compensation managed care
arrangement network. The medical care coordinator shall have experience or
training in workers' compensation and be responsible for the following:
1. Management of the medical treatment
plan;
2. Participation in the
quality improvement process and evaluation of outcomes of care;
3. Review of grievances; and,
4. Authorization of referrals to specialty
providers for second opinions, evaluation of treatment, including changes to
another specialty provider pursuant to section
440.134(10)(c),
F.S.
(h) Nothing in this
rule prohibits the use by a medical or osteopathic physician of advanced
practice registered nurses licensed under section
464.012, F.S., or physician's
assistants licensed under chapters 458 or 459, F.S., in accordance with and
within the scope of their professional licenses in Florida Statutes. An injured
employee shall be evaluated or treated by the physician supervising the
advanced practice registered nurse or physician assistant if specifically
requested by the injured employee.
(i) The insurer or delegated entity, may
direct injured employees to a single primary care provider or a selected group
of primary care providers within the provider network for assessment and
initial treatment. However, the employee shall have the right to select a
primary care provider and thereafter, to request one change of primary care
provider and of each authorized treating specialty provider during the course
of treatment for each injury. The injured employee shall select a primary care
provider from a current list of all primary care providers in the approved
service area within 30 minutes average travel time of the employee's employment
site.
(j) Initial and network
change applications shall contain information on the numbers, types, and
locations of health care providers which are included in the managed care
network. The types of providers to be included shall comply with those listed
on AHCA Form 3160-0005, November 2000, WCMCA Service Area Network Checklist,
incorporated herein by reference. This form is available from the agency by
contacting the Agency for Health Care Administration, Division of Managed Care
and Health Quality, Bureau of Managed Health Care, 2727 Mahan Drive, Mail Stop
#45, Tallahassee, Florida 32308.
(8) Delegation. The insurer shall conduct
oversight of the delegated functions of the workers' compensation managed care
arrangement. The insurer is responsible for the performance of all functions
associated with the delivery of medical services to injured employees under
section 440.134(1)(g),
F.S., regardless of whether the function has been delegated, by written
agreement, to other entities. The insurer shall specify, in the written
agreement, the oversight and reporting requirements for monitoring the
performance of delegated functions. Reports of subcontractors shall be
evaluated no less than quarterly, and the findings incorporated into the
insurer's quality assurance program.
Rulemaking Authority 440.134(25) FS. Law Implemented
120.57, 440.134(1)(g), (2)(a), (3), (4), (5), (6), (10), (12), (13), (14)
FS.
New 9-12-94, Amended 4-30-98,
5-8-01.
