59A-23.006. Grievance Procedures

(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.

(5) The insurer or delegated entity shall designate at least one grievance coordinator who is responsible for the implementation of the grievance procedure. The insurer or delegated entity shall ensure that the grievance coordinator’s role in the grievance procedure is identified in the grievance coordinator’s job description.

(6) The insurer or delegated entity shall provide specified phone numbers in the provider and employee educational materials for the employee or provider to contact the grievance coordinator. Each phone number shall be toll free within the injured employee’s or provider’s geographic service area and shall provide access without undue delays. There must be an adequate number of phone lines to handle incoming complaint calls.

(7) The insurer or delegated entity shall provide a current mailing address in employee and provider educational materials that indicate where to file a grievance.

(8) Physician involvement in reviewing medically related grievances. This involvement shall not be limited to the injured employee’s primary care physician, but shall include at least one other physician.

(9) A meeting between the insurer or delegated entity and the injured employee or provider during the written grievance process if requested by the injured employee or provider. The insurer or delegated entity shall offer to meet with the injured employee or provider at a location within the service area convenient to the injured employee or provider.

(10) A record of each written grievance. The insurer or delegated entity will maintain a record of each written grievance to include the following:

(a) A description of the grievance, the injured employee’s or provider’s name and address, the names and addresses of any treating workers’ compensation providers relevant to the grievance, and the managed care arrangement name and address;

(b) A complete description of the findings, including supportive documentation, conclusions and final disposition of the grievance; and,

(c) A statement as to the current status of the grievance.

(11) The insurer or delegated entity shall maintain a list of all grievance files that contains the identity of the injured employee, the individual filing the grievance, the date filed, the nature of the grievance, the resolution, and the resolution date.

(12) The insurer or delegated entity shall be responsible for regular and systematic review and analysis of all written grievances for the purpose of identifying trends or patterns, and, upon emergence of any pattern, shall develop and implement recommendations for corrective action.

(13) An annual report of all grievances filed by employees and providers shall be submitted to the Agency pursuant to Section 440.134(15)(g), F.S. The report shall list the number, nature, and resolution of all written employee and provider grievances. This report shall be submitted no later than March 31 for grievances filed during the previous calendar year in a format prescribed by the Agency on AHCA Form No. 3160-0012 (July 1997). This form is hereby incorporated by reference and is available by contacting AHCA, 2727 Mahan Drive, Tallahassee, Florida 32308, Bureau of Managed Health Care, Workers’ Compensation Managed Care Unit. It is also available at www.fdhc.state.fl.us/Managed Health Care/WCMC.

Rulemaking Authority 440.134(25) FS. Law Implemented 440.134(1)(b), (d), (5)(c), (e), (6)(b), (c), (7), (8), (10)(c), (14)(d), (15) FS. History–New 9-12-94, Amended 10-8-01, 1-22-02.