Current through Reg. 50, No. 187; September 24, 2024
(1) Each insurer
or delegated entity shall develop and implement a grievance procedure to
resolve complaints and written grievances by employees and providers.
(2) A detailed description of the employee
complaint and grievance procedure shall be provided by the insurer or delegated
entity to employees pursuant to Rule
59A-23.009, F.A.C. A detailed
description of the employee complaint and written grievance procedures shall be
included in educational materials provided to injured employees. A detailed
description of the provider complaint and grievance procedure shall be included
in educational materials given to providers.
(3) A copy of the grievance procedure and
forms for filing a written grievance shall be made available to providers,
employees, or their designated representative within seven calendar days of
receipt of a request. Copies of the form required for filing a grievance shall
also be available at the same location as the compensation notice required
under Rule 69L-6.007, F.A.C. The insurer or
delegated entity shall not charge the employer, employee, or provider for
administering the grievance process.
(4) The grievance procedure shall include the
following:
(a) Requests for services. The
insurer or delegated entity shall implement a procedure to address initial
requests for services. Initial requests for services, such as a request for
medical services, second opinions, or a change in providers, are not considered
a complaint or grievance. The insurer or delegated entity shall evaluate
requests for medical services within seven calendar days of receipt and shall
notify the injured employee of the decision to grant the request, to deny it,
or to request additional information. When the insurer or delegated entity
denies a request it shall notify the injured employee in writing of the denial
and the right to file a grievance. The insurer or delegated entity shall
provide the employee with a copy of AHCA Form No. 3160-0019 (November 2000)
which is incorporated by reference. If the insurer or delegated entity fails to
respond within seven calendar days of receipt of the request, the injured
employee may make a complaint or file a written grievance.
(b) Complaint Procedure. The insurer or
delegated entity shall implement a procedure to address complaints about
medical issues and employees' rights under Section
440.134, F.S., in a timely
manner in order to expedite the resolution of issues of providers and injured
employees.
1. The insurer or delegated entity
shall investigate and resolve a complaint within ten calendar days of receipt
unless the parties and the insurer or delegated entity mutually agree to an
extension. The ten days shall commence upon receipt of a personal or telephone
contact by the insurer or delegated entity from the injured employee, provider,
designated representative, the Agency, or the Division.
2. If a complaint is denied, or remains
unresolved after ten days of receipt, the insurer or delegated entity shall
notify the affected parties in writing of the right to file a written
grievance. If the insurer or delegated entity denies a complaint, it shall
notify the injured employee of the reason for the denial. The written
notification shall include the name, title, address, and telephone number of
the grievance coordinator. In addition, the insurer or delegated entity shall
advise the injured employee of the right to contact the Division's Employee
Assistance Office for additional information on rights and responsibilities and
the dispute resolution process under Chapter 440, F.S., and related
administrative rules; and,
(c) Written Grievance. The procedure for
written grievances shall commence upon receipt of a signed grievance form AHCA
Form No. 3160-0019 (November 2000) by the insurer or delegated entity, from the
injured employee, provider, or their designated representative. A written
grievance may be submitted or withdrawn at any time. The injured employee or
provider is not required to make a complaint prior to filing a written
grievance. The procedure shall include notice to the employer when a grievance
has been filed. The insurer or delegated entity shall notify the injured
employee and employer in writing of the resolution of the written grievance,
and the reasons therefore within seven days of the final determination.
1. The insurer or delegated entity shall
implement an expedited procedure for urgent grievances to render a
determination and notify the injured employee within three calendar days of
receipt. If the insurer or delegated entity has initiated an expedited
grievance procedure, the injured employee shall be considered to have exhausted
all managed care grievance procedures after three days from receipt.
2. Upon receipt of a written grievance, the
grievance coordinator shall gather and review medical and related information
pertaining to the issues being grieved. The grievance coordinator shall consult
with appropriate parties and shall render a determination on the grievance
within 14 calendar days of receipt. If the determination is not in favor of the
aggrieved party the grievance coordinator shall notify the aggrieved party that
the grievance is being forwarded to the grievance committee for further
consideration unless withdrawn in writing by the employee or
provider.
3. The grievance
committee shall consist of not less than three individuals, of whom at least
one must be a physician other than the injured employee's treating physician,
who is licensed under Chapters 458 or 459, F.S., and has professional expertise
relevant to the issue. The committee shall review information pertaining to the
issues being grieved and render a determination within 30 calendar days of
receipt of the grievance by the committee unless the grieving party and the
committee mutually agree to an extension that is documented in writing. If the
grievance involves the collection of additional information from outside the
service area, the insurer or delegated entity will have 14 additional calendar
days to render a determination. The insurer or delegated entity shall notify
the employee in writing within seven days of receipt of the grievance by the
committee if additional information is required to complete the review of the
grievance.
4. The insurer or
delegated entity may allow but may not require arbitration as part of the
grievance process. A grievance which is arbitrated pursuant to Chapter 682,
F.S., is permitted an additional time limitation not to exceed 210 calendar
days from the date the insurer or delegated entity receives a written request
for arbitration from the injured employee. Arbitration provisions in a workers'
compensation managed care arrangement shall not preclude the employee from
filing a request for assistance with the Division of Workers' Compensation
relating to non-medical issues.
5.
An injured employee or provider grievance shall be submitted on AHCA Form No.
3160-0019, November 2000. The insurer or delegated entity shall provide
assistance to an injured employee unable to complete the grievance form and to
those persons who have improperly filed a grievance.
6. The claimant or provider shall be
considered to have exhausted all managed care grievance procedures if a
determination on a grievance has not been rendered within the required
timeframe specified in this section or other timeframe, as mutually agreed to
in writing by the grieving party and the insurer or delegated entity.
7. Upon completion of the grievance
procedure, the insurer or delegated entity shall provide written notice to the
employee of the right to file a petition for benefits with the Division
pursuant to Section 440.192,
F.S.
(5) The
insurer or delegated entity shall designate at least one grievance coordinator
who is responsible for the implementation of the grievance procedure. The
insurer or delegated entity shall ensure that the grievance coordinator's role
in the grievance procedure is identified in the grievance coordinator's job
description.
(6) The insurer or
delegated entity shall provide specified phone numbers in the provider and
employee educational materials for the employee or provider to contact the
grievance coordinator. Each phone number shall be toll free within the injured
employee's or provider's geographic service area and shall provide access
without undue delays. There must be an adequate number of phone lines to handle
incoming complaint calls.
(7) The
insurer or delegated entity shall provide a current mailing address in employee
and provider educational materials that indicate where to file a
grievance.
(8) Physician
involvement in reviewing medically related grievances. This involvement shall
not be limited to the injured employee's primary care physician, but shall
include at least one other physician.
(9) A meeting between the insurer or
delegated entity and the injured employee or provider during the written
grievance process if requested by the injured employee or provider. The insurer
or delegated entity shall offer to meet with the injured employee or provider
at a location within the service area convenient to the injured employee or
provider.
(10) A record of each
written grievance. The insurer or delegated entity will maintain a record of
each written grievance to include the following:
(a) A description of the grievance, the
injured employee's or provider's name and address, the names and addresses of
any treating workers' compensation providers relevant to the grievance, and the
managed care arrangement name and address;
(b) A complete description of the findings,
including supportive documentation, conclusions and final disposition of the
grievance; and,
(c) A statement as
to the current status of the grievance.
(11) The insurer or delegated entity shall
maintain a list of all grievance files that contains the identity of the
injured employee, the individual filing the grievance, the date filed, the
nature of the grievance, the resolution, and the resolution date.
(12) The insurer or delegated entity shall be
responsible for regular and systematic review and analysis of all written
grievances for the purpose of identifying trends or patterns, and, upon
emergence of any pattern, shall develop and implement recommendations for
corrective action.
(13) An annual
report of all grievances filed by employees and providers shall be submitted to
the Agency pursuant to Section
440.134(15)(g),
F.S. The report shall list the number, nature, and resolution of all written
employee and provider grievances. This report shall be submitted no later than
March 31 for grievances filed during the previous calendar year in a format
prescribed by the Agency on AHCA Form No. 3160-0012 (July 1997). This form is
hereby incorporated by reference and is available by contacting AHCA, 2727
Mahan Drive, Tallahassee, Florida 32308, Bureau of Managed Health Care,
Workers' Compensation Managed Care Unit. It is also available at
www.fdhc.state.fl.us/Managed
Health Care/WCMC.
Rulemaking Authority 440.134(25) FS. Law Implemented
440.134(1)(b), (d), (5)(c), (e), (6)(b), (c), (7), (8), (10)(c), (14)(d), (15)
FS.
New 9-12-94, Amended 10-8-01,
1-22-02.
