Current through Reg. 50, No. 187; September 24, 2024
(1) Employee
Education.
(a) The insurer or delegated entity
in conjunction with the employer, shall develop and implement procedures for
the education of employees about the managed care process and requirements. The
education procedures shall include:
1.
Orientation of all existing and new employees to the requirements and
limitations of the workers' compensation managed care arrangement. The employer
shall display a telephone number for obtaining information about the workers'
compensation managed care arrangement in a prominent location in the
workplace;
2. Provision of detailed
employee education materials about the requirements and limitations of the
workers' compensation managed care arrangement to the injured employees; and,
3. Ongoing education of employees
about changes in the workers' compensation managed care
arrangement.
(b) The
insurer or delegated entity shall provide, either directly or indirectly,
employee educational materials written in language common to the workforce in
the geographic service area. Whether or not the employer has provided
educational materials previously, the educational material shall be provided to
an injured employee within three calendar days of the date that the notice of
injury is filed by the insurance carrier or the employer. The content of the
employee educational material shall include:
1. The rights and responsibilities of the
injured employee;
2. A description
of the process for accessing medical care including the use of network
providers, the primary care provider, medical care coordinator, case
management, and the procedure to request a referral to a specialist;
3. The possible effect to the injured
employee's health and benefits for failure to use network providers or
obtaining authorization for specialty care;
4. A description of the process for changing
primary care and other specialty providers once within the same specialty as
the authorized treating physician during the course of treatment for a
work-related injury;
5. A
description of the procedure for obtaining a second opinion;
6. A description of the complaint and
grievance process including the procedure to file a complaint or grievance,
timeframes for completion of a complaint or grievance, and the availability of
a grievance form;
7. The toll free
telephone number of the grievance coordinator; and,
8. The telephone number of the Division of
Workers' Compensation, Employee Assistance Office toll free
hotline.
(c) The insurer
or delegated entity shall ensure that all injured employees are provided a
current list of network providers within the service area in which the
individual is employed. The insurer or delegated entity shall provide a copy of
the list to the employee or designated representative within five calendar days
of receipt of a request.
(2) Provider Education. The insurer or
delegated entity shall ensure that the health care providers within the
provider network have received training and education on the provisions of
Chapter 440, F.S., and related administrative rules. This shall be accomplished
by a provider education program or verification that providers have previously
received certification from the Division pursuant to Section
440.13, F.S.
(a) The provider education program shall
address the following:
1. The mission and
goals of workers' compensation managed care;
2. Roles, rights, and
responsibilities;
3. Provider
network procedures;
4. Case
management procedures;
5. Practice
guidelines;
6. Utilization
management procedures;
7. Peer
review procedures;
8. Dispute
resolution and grievance procedures;
9. Communication procedures between managed
care components;
10. Medical
records and case file procedures;
11. Workers' compensation managed care
statutes and regulations relating to remedial treatment; and,
12. The health care provider's role in
successful return to work.
(b) The insurer or delegated entity shall
identify those ancillary providers who require training on the provisions of
workers' compensation medical services and shall provide and document the staff
training and education program.
(c)
The insurer or delegated entity shall provide such ongoing provider education
at least annually to keep providers informed of changes in the processes of the
workers' compensation managed care arrangement and to correct problems and
implement recommendations of the quality assurance program. The insurer or
delegated entity shall document the provision of training.
(3) Administrative Staff Education.
The insurer or delegated entity shall develop and implement a
policy and procedure, and implement a process, to identify and train those
administrative staff who require training on the provisions of Chapter 440,
F.S., and related administrative rules. Administrative staff shall include case
managers, the grievance coordinator, and claims representatives. The insurer or
delegated entity shall document the staff training and education program. The
program content shall address the following:
(a) The mission and goals of workers'
compensation managed care;
(b)
Roles, rights, and responsibilities;
(c) Provider network procedures;
(d) Case management procedures;
(e) Practice guidelines;
(f) Utilization management
procedures;
(g) Peer review
procedures;
(h) Dispute resolution
and grievance procedures;
(i)
Communication procedures between managed care components; and,
(j) Medical records and case files
procedures.
Rulemaking Authority 440.134(25) FS. Law Implemented
440.134(1)(b), (d), (g), (i), (j), (k), (3), (5)(a), (c), (e), (6)(b), (c)2.,
3., 4., 6.-10., (7), (8), (10)(a)-(d), (11), (12), (14)(a)-(d), (15)(a)-(f),
(17) FS.
New 10-8-01.
