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-23.006 - Grievance Procedures

Current through Reg. 50, No. 138; July 16, 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.