Fla. Admin. Code R. 59A-23.009

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

Section 59A-23.009 - Education Procedures

(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.

Fla. Admin. Code Ann. R. 59A-23.009

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.