Fla. Admin. Code R. 59A-23.003

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59A-23.003 - Authorization Procedures

(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.

Fla. Admin. Code Ann. R. 59A-23.003

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.