Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59A - Health Facility and Agency Licensing › Chapter 59A-23 - WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS › Section 59A-23.002 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
(1) "Agency" means the Agency for Health Care
				Administration.
(2) "Case files"
				means a system for managing medical information and return to work information
				regarding the injured employee, whether in electronic or paper
				format.
(3) "Complaint" means any
				dissatisfaction expressed by an injured worker as defined in Section
				440.134(1)(b),
				F.S. An initial request for services, such as a request for medical services,
				second opinions, or a change in providers, is not considered a
				complaint.
(4) "Delegated entity"
				means a unit or single organization authorized by written agreement to act on
				behalf of the insurer to provide managed care services.
(5) "Credentialing" means the process for
				validating and evaluating the qualifications of a licensed health care provider
				to participate in a workers' compensation managed care arrangement provider
				network.
(6) "Division" means the
				Division of Workers' Compensation of the Florida Department of Labor and
				Employment Security.
(7) "External
				case management" means face-to-face medical care coordination performed by a
				qualified rehabilitation provider pursuant to Section
				440.491, F.S.
(8) "Grievance" means a written expression of
				dissatisfaction with medical care by an injured worker as defined in Section
				440.134(1)(d),
				F.S. Initial written requests for medical services, second opinions, or changes
				in providers are not grievances.
(9) "Insurer" means an entity which contracts
				to provide workers' compensation insurance coverage as defined under Section
				440.134(1)(e),
				F.S.
(10) "Internal case
				management" means a process for telephonically coordinating, facilitating, and
				monitoring all aspects of the medical care coordination of the injured employee
				in consultation with the treating physician and the medical care
				coordinator.
(11) "Medical care
				coordination" means active case management and coordination of the health care
				services for an injured employee involving a medical care coordinator to ensure
				the delivery of necessary services in a manner which will return the individual
				to work as soon as feasible.
(12)
				"Peer review" means the evaluation of the treatment plan or clinical
				performance of providers by one or more licensed professionals with the same
				authority or similar specialty when potential quality of care issues have been
				identified through case management or quality assurance processes.
(13) "Quality assurance" means a formal set
				of activities, which review and safeguard the quality of medical services
				provided to the injured employee. Quality assurance includes assessment and
				implementation of corrective actions to address any deficiencies identified in
				the quality of care and services provided to the injured employee.
(14) "Second medical opinion" means a
				consultation by a health care provider authorized by the medical care
				coordinator that requires at a minimum a history, an examination, and a
				straightforward medical decision to confirm or offer alternatives.
(15) "Service area" means a geographic area
				consisting of a county or group of counties which shall not be subdivided for
				purposes of authorizing a workers' compensation managed care
				arrangement.
(16) "Utilization
				management" means the examination and evaluation of health care services to
				determine the appropriate use of the resources and components available within
				the workers' compensation managed care arrangement including, retrospective,
				concurrent, and prospective care reviews.
(17) "Urgent" means that in the judgment of
				the primary care physician or medical care coordinator, the injured employee's
				clinical condition requires a response within 72 hours, and the clinical
				condition is at significant risk of deterioration if a response is not made
				within that timeframe.
(18)
				"Written agreement" means an express, legally executed, written contract
				between two or more parties which specifies the following: the parties to the
				contract; the effective date of the contract; duties of the respective parties;
				reporting and or oversight of the responsibilities to be performed; performance
				standards; termination and expiration terms of the contract.
(19) "Workers' Compensation managed care
				arrangement" means those arrangements as defined under Section
				440.134(1)(g),
				F.S.
Rulemaking Authority 440.134 FS. Law Implemented
					 440.134(1)(g), (5)(a), (6)(b), (c), (c)4., 6.-9., (9), (10), (14)(b), (d),
					 (16), (17), (25)(b), (c), (d), (g) FS.
New 9-12-94, Amended 10-8-01,
					 1-22-02.