59A-23.002. Definitions

(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. History–New 9-12-94, Amended 10-8-01, 1-22-02.