Table of Contents

• Introduction
  
• Definitions
  
• Reporting a Workers' Compensation Claim
  
• General Procedures
  
• Grievance Policy and Procedures
• Forms

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Introduction

For dates of accident on or after January 1, 2003, the Division of Risk Management's managed care administrator is CorVel Corporation. Section 440.134(17). Florida Statues requires injured workers to utilize care providers who are part of the employer's managed care arrangement (MCA).

This process ensures quality medical care delivery. The goals are:

• To ensure the injured worker receives quality, cost effective medical care;
• To ensure medical care is geared toward expedient recovery;
• To ensure the appropriateness of hospitalization;
• To ensure injured employees to CorCare network providers and physicians; and
• To return the employee back to work as quickly as medically feasible.

On weekend, holidays, or in the evening, FSU employees should contact CorVel directly at 1-800-929-0107 to report an injury and receive instructions.

In a medical emergency, transport the injured worker to the nearest medical facility or call 911 for assistance. Following the arrangement of emergency treatment for the injured employee, contact Corvel 1-800-929-0107.

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Definitions

Managed Care Arrangement - The arrangements under Florida statute 440.134; means an arrangement under which a provider of health care, a health care facility, a group of providers of health care, a group of providers of health care and health care facilities, or an insurer that has an exclusive PPO or HMO has entered into a written agreement directly or indirectly with an insurer to provide and to manage appropriate remedial treatment, care and attendance to injured workers.

Medical Care Coordinator - A primary care physician within a provider network who is responsible for managing the medical care of an injured worker, including other providers and facilities to which the injured employee will be referred. A medical care coordinator shall be a physician licensed under Chapter 458 or an osteopath licensed under Chapter 459.

Provider Network - A comprehensive panel of health care providers and health care facilities who have contracted directly or indirectly with an insurer to provide appropriate remedial treatment, care and attendance to injured workers in accordance with Chapter 440.

Primary Care Provider - With the exception of emergency treatment, the initial treating physician and when appropriate, continuing treating physician, who may be a family practitioner or internal medicine physician licensed under Chapter 458; a family practitioner, general practitioner, or internal medicine osteopath licensed under Chapter 459; a chiropractor licensed under Chapter 460; a podiatrist licensed under Chapter 461; an optometrist licensed under Chapter 463; or a dentist under Chapter 466.

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Reporting a Workers' Compensation Claim

What to do if an injury occurs:

1. Notify your supervisor immediately. Even if you do not think you need medical care, you should contact your supervisor to discuss you injury.
2. Contact CORVEL Corporation at (800) 929-0107 to report injury and obtain medical authorization prior to obtaining medical treatment.
3. Follow-up with W/C Coordinator to inform of injury.
4. Provide both your supervisor and FSUWC with medical documentation of your initial work status and any subsequent changes to it.
5. Maintain contact with your supervisor in order to keep him/her informed about your treatment and recovery.
6. Attend all of your scheduled medical appointments. Failure to do so may result in disciplinary action up to and including termination.
7. When your medical care provider releases you to return to work (regardless of your assigned limitations or restrictions), you must be willing and available to return to the workplace.

Contact FSUWC:

• If you are unable to attend a scheduled medical appointment.
• For assistance if you have concerns related to your claim or require additional medical attention.
• If your work unit does not provide you with modified duty work.
• If you are uncertain as to which medical care providers are authorized providers.

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General Procedures

Primary Care Provider Selection by the Employee: When an injury is reported, CorVel's Intake Unit will assist you with selection of a provider from the CorCare Network. Additionally you will be given assistance in appointment scheduling and follow through if necessary. The workplace poster (located at your work site) will serve as a reminder of the Managed Care Arrangement program and steps to take when reporting an injury and seeking medical treatment.

Changing your Physician: You are allowed one change to another provider. Your request may be directed to the treating physician, your medical care coordinator (in most cases this will be your treating physician), your CorVel case manager or your claims adjuster. The provider must be of the same specialty and within the CorCare Network. If you desire a second change of provider, you must file a grievance.

Grievance Procedure: The Division of Risk Management encourages open and effective communication between all parties involved in the Managed Care Arrangement. As a part of effective communication, The Division of Risk Management in conjunction with CorVel Corporation has implemented a procedure for hearing complaints and resolving grievances from injured workers and health care providers. This process allows for immediate action aimed at achieving mutual agreement for settlement among all involved parties. Please see "Grievance Policy and Procedures" for complete details.

Employee Request for a Second Medical Opinion: Injured workers have the opportunity to request and obtain one second medical opinion in the same specialty within the Provider Network. This process is as follows:

1. A request is generated from the employee either by phone or in writing to the case manager or claims adjuster.
2. The case manager conferences with the employee to confirm understanding of the request and to explain the procedure. The request is forwarded to the medical care coordinator.
3. The medical care coordinator approves the request and a Network provider is selected.
4. The case manager notifies the treating physician of the new provider.

Independent Medical Examination (IME): Should you or the Division of Risk Management wish for an independent medical exam to be performed due to a dispute concerning medical benefits, compensability or disability, you must contact the CorVel Corporation medical case manager immediately (either verbally or in writing). The medical case manager will coordinate the medical exam.

Workers' Compensation Prescription Drug Program: CorVel offers a comprehensive prescription drug program. The program includes utilization reporting which allows for early intervention and effective claims management.

A pharmacy card is mailed to the injured worker upon notice of a claim and network pharmacies also receive electronic notification. For more information about the drug program, please call 1-800-749-2481.

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Grievance Policy and Procedures

Policy

To take appropriate, prompt corrective action when necessary to address valid complaints and grievances.

• The complaints/grievances shall be thoroughly investigated using supportive and written information from both parties.
• Complaints and grievances will be handled in a timely manner following the appropriate procedures.
• If a grievance is valid, appropriate quality improvement steps will be taken to handle the individual issue and also to prevent a recurrence.
• Education will be an important part in the corrective action process.

Procedure

Your employer encourages open and effective communication between all parties involved in the Managed Care Arrangement. As a part of effective communication, your employer in conjunction with CorVel Corporation will implement the following procedures for hearing complaints and resolving grievances from injured workers and health care providers. This process allows for immediate action aimed at achieving mutual agreement for settlement among all involved parties. The designated form as prescribed by this Managed Care Arrangement will be utilized for the filing of grievances. (See AHCA 3160-0019 (November 2000) Grievance Form included in this packet). The AHCA 3160-0019 (November 2000) Grievance Form is also available from your employer.

Definitions

Request for Services - Initial request for services, request for medical services, second opinions, or a change in providers.

Complaint - Dissatisfaction expressed by an injured worker or provider concerning medical issues and employees' rights concerning an insurer's workers' compensation managed care arrangement.

Written Grievance - A written expression of dissatisfaction with the medical care by an injured worker by an insurer's workers' compensation managed care arrangement health care providers, utilizing the AHCA Form No. 3160-0019 (November 2000) Grievance Form

Urgent Grievance - An urgent grievance 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.

Grievance Coordinator - A member of the CorVel Quality Assurance Committee who is responsible for the implementation and follow through of the grievance process and procedures.

Grievance Committee - A committee designated to review and resolve written grievances. The Committee will consist of three or more of: the employer representative, grievance coordinator, case manager, MCC and/or PCP, medical advisor, or CorVel Administration Representative. One member must be a physician other than the treating physician who has expertise relevant to the issue and licensed under Chapter 458 or 459, F.S.

Grievances are to be mailed to:

CorVel Corporation
Attn.: Grievance Coordinator
725 Primera Blvd. #210
Lake Mary, FL 32746

If desired by the employee or provider, a meeting will be held between the medical advisor, nurse case manager and the provider during the grievance process. Upon request by the employee or CorCare provider, CorVel Corporation will allow for a meeting at its administrative offices within the service area convenient to the employee or provider.

General Procedures

Requests for Services

• If the injured worker has an initial request for service, such as a request for medical services, second opinions, or a change in providers, they may contact their case manager, adjuster, medical care coordinator or the grievance coordinator. Initial requests for medical assistance or services are forwarded to the medical care coordinator for approval or denial of the request.

• The party receiving the request for services will document the nature of the request and forward it along with the resolution to the grievance coordinator for tracking and trending purposes.

• At the time, the injured employee will be informed of the steps that will be taken to help resolve the particular concern, as well as, the expected time frame for resolution. It is understood that request for services must be resolved within seven (7) calendar days upon receipt of the request from the injured employee, unless the parties mutually agree to an extension. If the matter is resolved, there is no further action.

• If the request for service is denied or remains unresolved after seven (7) days of receipt, the injured employee shall be notified in writing of the results and advised of their right to make a complaint or file a written grievance. A copy of the AHCA Form No. 3160-0019 (November 2000) shall be provided to the injured employee.

Complaints

• If the injured worker has a complaint related to a medical issue, they may contact their case manager, adjuster, medical care coordinator or the grievance coordinator either telephonically or in person. Initial requests for medical assistance or services are forwarded to the managed care coordinator for approval or denial of the request.

• The party receiving the complaint will document the nature of the complaint and forward it along with the resolution to the grievance coordinator for tracking and trending purposes.

• At the time, the complainant will be informed of the steps that will be taken to help resolve the particular concern, as well as, the expected time frame for resolution. It is understood that complaints must be resolved within ten (10) calendar days upon receipt of a personal or telephone contact from the injured employee, unless the parties mutually agree to an extension. If the matter is resolved, there is no further action.

• If the complaint is denied or remains unresolved after ten (10) days of receipt, the complainant shall be notified in writing of the results and advised of their rights to activate the grievance process. The written notification shall include the name, address and toll-free telephone number of the grievance coordinator responsible for activating the grievance steps. In addition, the complainant shall be advised of their rights to contact the Division's Employee Assistance Office for additional information on rights and responsibilities and the dispute resolution process.

Written Grievance

• The injured employee fills out the Grievance Form (AHCA Form 3160-0019 November 2000).

• The grievance coordinator will provide assistance to an injured worker unable to complete the grievance form and to those persons who have improperly filed a grievance.

• Upon receipt of the 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.

• The grievance 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 grievance committee unless the injured employee or provider and the grievance committee mutually agree to an extension that is documented in writing. If the grievance involves the collection of information outside the service area, the grievance coordinator will have fourteen (14) additional calendar days to render a determination. The grievance coordinator will notify the employee or provider in writing within seven days of receipt of the grievance by the grievance committee if additional information is required to complete the review of the grievance.

• Upon receipt of a written urgent grievance, the grievance coordinator shall consult with appropriate parties and determine a resolution or forward the urgent grievance to the grievance committee to render a determination and notify the injured employee within three (3) calendar days of receipt. If grievance coordinator has initiated an expedited grievance procedure, the injured employee shall be considered to have exhausted all managed care grievance procedures after three (3) days of receipt.

• Upon completion of the grievance procedure, the grievance coordinator shall provide written notice to the injured employee of the right to file a Petition for Benefits with the Division. An injured employee may contact the local Employee Assistance Office of the Division at (800) 342-1741 prior to filing a Petition for Benefits.

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Forms

• Formal Grievance Form

• Employee Acknowledgement

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