Managed Care Program

Transcription

1 Summit Workers Compensation Managed Care Program FLORIDA How to obtain medical care for a work-related injury or illness.

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3 Welcome The Summit workers compensation managed-care arrangement (Summit MCA) is a cooperative effort between your company s workers compensation insurer and Heritage Summit HealthCare LLC, a Summit subsidiary. The objective of the Summit MCA is to form a partnership with its members to manage the medical aspects of work-related injuries for member companies. We encourage you to read this handbook and become familiar with the steps for using the Summit MCA when you need medical care for a work-related injury or illness. Treatment received outside the workers compensation managedcare arrangement, excluding true emergencies, is generally not covered unless authorized by the Summit MCA. Please remember that any person who knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program files a statement of claim containing any false or misleading information commits a felony of the third degree. If you have any questions, please call your Summit MCA medical services coordinator or case manager at

4 Table of Contents What Is Workers Compensation?...3 Your Workers Compensation Program: Managed Care...3 Your Rights And Benefits...3 General...3 Medical care...3 Prescriptions...3 Your Responsibilities...4 If you get hurt on the job and it is an emergency...4 If you get hurt on the job and it is not an emergency...4 If you re outside the state of Florida, away from the worksite, or outside the service area of the managed-care arrangement...4 If you need surgery or hospitalization...5 While receiving treatment...5 Drug and/or alcohol testing...5 Safety requirements...5 Return to work...5 Workers compensation fraud...5 Grievance Procedures...6 Initial special requests...6 Complaint procedure...6 What is a grievance?...6 How to file a grievance...7 Responsibilities of the Summit MCA...8 2

5 What Is Workers Compensation? A Florida workers compensation policy pays medical and disability benefits when an employee s injury or illness arises out of and in the course of employment. Workers compensation benefits are regulated by the state of Florida and are set by law. Your Workers Compensation Program: Managed Care Under the Florida workers compensation law, Summit operates a workers compensation managed-care arrangement to provide medical care for injured workers. The Summit managed-care arrangement (MCA) works with you and your designated doctor to provide treatment that is appropriate and that will help you return to work as soon as medically possible. Your Rights and Benefits General information Your employer purchased this workers compensation insurance coverage at no cost to you. This coverage will pay for all reasonable and necessary medical care if you get injured at work or develop an occupational disease arising out of and in the course of your employment. You are covered from your first day of work on the job. If you are injured on the job, you may be required to take a drug and/or alcohol test. If you test positive for alcohol or illegal drugs at the time of your injury, you may not be entitled to workers compensation benefits under this program according to Florida law. You have the right to copies of any medical reports you request. (There is a charge of 50 per page for photocopies, and we will bill you actual cost for X-rays or nonpaper documents.) Medical care Care that is medically necessary will be given at no cost to you. Medical care includes approved surgical, hospital and dental care, prescriptions and medical supplies. Generally, you must use health care providers in Summit s medical provider network for treatment of your work-related injury. Care must be authorized by the Summit MCA. Your employer has called Summit to report your injury and will let you know about the providers you should see. Also, a complete provider directory is available on the Summit website, summitholdings.com. If you go out of the network to seek medical care, your benefits will not be covered except in the case of a limb-or life-threatening emergency. A Summit MCA treatment facility is available to provide medical care near your worksite. You should go there for care unless it is an emergency or unless you are told otherwise by Summit. Your company s workers compensation plan will pay providers directly for authorized services. If you receive provider bills, do not pay them. Instead, please call the Summit Claims Center or mail them to the following address: Prescriptions Summit Claims Center P.O. Box 2928 Lakeland, FL Summit has a prescription drug program especially for injured workers. Express Scripts administers this program and has contracted with many pharmacies and retail chains in your area, such as Publix, Wal- Mart, Kmart, CVS, Walgreens and Rite Aid. If you are injured on the job, your employer should have given you a completed First Prescription Fill (Letter of Intent) form before you went to the doctor. If you receive prescriptions for your injury, you will need to present this form to the pharmacist when you get your first workers comp-related prescription 3

6 filled. This form enables you to receive an initial 7-day supply (maximum) of medications prescribed for your injury. A complete list of participating pharmacies is included on this form. At the time your claim is reported, a prescription card will be generated and mailed to you for future prescriptions related to your injury. You should receive your prescription card within one week of your injury. Simply present the card to your pharmacist for refills or any new prescriptions after your initial 7-day supply. To obtain more information about participating pharmacies or for authorization to have a prescription filled (without the First Fill letter), please contact Summit at (Monday Friday, 8:00 a.m. 5:30 p.m. Eastern Time). Any pharmacy outside the network should bill the program directly by mailing invoices to the following address: Summit Claims Center P.O. Box 2928 Lakeland, FL If you pay the bill yourself, send the receipt to the address shown above. Your receipt must include the following information: date dispensed, new or refill, prescription number, medication name and strength, National Drug Control number, quantity dispensed, number of days supplied, reason for use of non-generic drug (when applicable), prescribing physician s name and state license number (from Florida s Department of Health, Division of Medical Quality Assurance) and the charge for each medication billed. Your Responsibilities If you get hurt on the job and it is an emergency... Have someone call 911 or take you to the nearest emergency room. Your supervisor or another responsible person must call Summit at as soon as possible after an injury requiring emergency care. Summit will coordinate additional care for you as needed and may make arrangements for a drug and/ or alcohol test. If you get hurt on the job and it is not an emergency... Tell your supervisor about your injury or illness immediately. Your supervisor must call Summit at for treatment authorization. You and your employer will be assisted by a Summit representative who will help you identify an appropriate network facility as well as provide that facility with the necessary authorizations for treatment. Through this process, you will be able to choose your primary care physician. Go to or have someone take you to the nearest Summit MCA facility or to the physician indicated by the Summit MCA. If you arrive at the facility and Summit has not yet been notified of your injury, the facility must call Summit before providing treatment. The Summit MCA physician(s) will treat you and may perform a drug and/or alcohol test. Summit will work with the physician to set up any other treatment needed and to get you back to work as soon as possible. If you re outside the state of Florida, away from the worksite, or outside the service area of the managed-care arrangement... Normally, you will go to the Summit MCA facility closest to your worksite for care. However, if you are outside the state of Florida or away from your worksite, call Summit before seeking treatment. We will refer you to a nearby provider within our network whenever possible. 4

7 If you need surgery or hospitalization... Summit must authorize all surgery or hospital admissions except in emergency situations. The physician or hospital must call Summit at for authorization. If Summit determines that the procedure or admission is not medically necessary, the medical director may contact the physician for further discussion or to develop an alternative plan of care. Summit may request a second opinion. While receiving treatment... You may ask for one change of physician during the course of treatment for a work-related injury by calling Summit at The Summit MCA medical services coordinator or case manager will select a physician within the network for you. You may ask for additional physician changes by contacting Summit by phone or mail, and your request will be handled through our grievance process. Please see page 7 to learn how to file a grievance. Your Summit MCA physician may refer you to another Summit MCA physician or specialist, if needed. The other physician or specialist will consult with Summit s medical services coordinator or case manager to arrange for additional tests or care, as needed. You (or Summit) may request that an independent medical exam be performed when there is a dispute concerning overutilization, medical benefits, compensability or disability. You must contact your medical services coordinator or case manager for assistance. You are responsible for keeping all your scheduled appointments. If you have any problems, call us at Your medical services coordinator or case manager will be glad to help you. Drug and/or alcohol testing If you are injured on the job and test positive for illegal drugs or alcohol, you may be denied your workers compensation benefits. If you refuse or fail to take a drug test, your workers compensation benefits may be denied. Part of our care management focuses on avoiding prescription drug complications and /or misuse. If you are injured at work and receive prescribed medications as part of your treatment, you may need to complete a separate medical questionnaire and a toxicology screen. Although these extra tests are usually limited to patients who have been prescribed controlled substances, they may also be used on a random basis, subject to Summit s discretion. There will never be an additional charge to you for these tests. It is important to remember that if you refuse to take a drug test or fail one, your workers compensation benefits may be denied. Safety requirements You must wear and use any safety equipment required by your employer. If you do not use required safety equipment or if you fail to observe safety rules and then get hurt, your workers compensation benefits may be reduced. Return to work If you have a workplace injury, your employer wants and needs you to come back to work as soon as you are able. You are expected to keep in touch with Summit and with your employer so that all parties know how you are progressing. You are expected to return to work in your normal job or a temporary modified job as approved by your physician. If you refuse to return to work, you may not be eligible for workers compensation wage benefits. Workers compensation fraud Filing a false workers compensation claim is a crime and is punishable under the applicable Florida workers compensation law, chapter

8 Fraudulent workers compensation claims are investigated by the Florida Department of Insurance and the FBI and are reported to the authorities immediately. You can help stop these crimes by reporting any suspected abuses directly to us by calling Grievance Procedures for the Summit MCA Our goal is to provide quality medical care to injured employees covered by the Summit managedcare arrangement (Summit MCA), and we know that there may be times when you have questions, concerns or complaints regarding the medical services provided. The following procedures were designed to ensure that any of your questions or complaints are handled in a timely manner. Initial requests Initial special requests include but are not limited to medical services, second opinions or a change in providers, and are not considered complaints or grievances. Such requests and any questions or concerns regarding your care for a work-related injury should be directed to your Summit MCA medical services coordinator or case manager. They are available to answer your questions Monday through Friday, 8:00 a.m. to 5:30 p.m Eastern Time. Just call Summit at We want to answer any questions and resolve any issues you may have through an informal process whenever possible. If you are not satisfied after speaking with your medical services coordinator or case manager, you may ask to speak with a supervisor, who will assist you at that time. We will notify you of our decision, or we may request additional information. If you do not receive a response within seven days of our receipt of your request, you may file a complaint or grievance. Additionally, if we deny the request, you will have the right to file a complaint or written grievance. [The grievance form (AHCA Form No November 2000) is enclosed in this booklet.] Complaint procedure* A complaint is any dissatisfaction you may express as defined in the Florida Statutes (F.S.) Section (1)(b). Remember that an initial request (including a request for medical services, second opinions or a change in providers) is not considered a complaint. Upon receipt of your personal complaint (written or verbal), we will investigate and attempt to resolve it within 10 calendar days of receipt of the complaint. If all parties agree, an extension may be granted. If a complaint is denied or remains unresolved after 10 days of its receipt, you will have the right to file a written grievance. [The grievance form (AHCA Form No November 2000) is enclosed in this booklet.] What is a grievance? A grievance is a written expression of dissatisfaction with medical care by an injured worker as defined in Section (1)(d), F.S. Based on the serious nature of a formal grievance, the following procedure was designed to ensure that you receive the most comprehensive review of the information possible and a timely response. (Initial written requests, including requests for medical services, second opinions or changes in providers, are not grievances.) Summit will report all formal grievances to the Agency for Healthcare Administration no later than March 31 for grievances filed during the previous calendar year. * The injured employee is encouraged to make a complaint prior to filing a written grievance. However, this process is not mandatory. 6

9 How to file a grievance To file your written grievance, you must complete the grievance form (AHCA Form No November 2000), which is enclosed in this booklet. We accept no other form or letter as a written grievance. Written grievances must be mailed to the following address: Summit Claims Center Attention: Summit MCA Grievance Coordinator P.O. Box 2928 Lakeland, FL The grievance form must include a summary of the issue, including all specifics, such as names, dates and origin of the issue. The summary must also include a statement of the action you are requesting of the Summit MCA, along with all supporting documentation for each issue. The Summit MCA will initiate the grievance process upon receipt of the grievance form, which can only be filed after the initial request(s) for medical services. Upon receipt of the grievance form, the Summit MCA medical services coordinator and case manager will work together with the grievance coordinator to gather and review medical information. An initial determination on granting or denying the grievance occurs within 14 calendar days of receipt of a properly filed grievance. If an incomplete grievance form or improper filing occurs, this shall be considered a complaint. If the grievance is initially denied, it will be forwarded to the Formal Grievance Committee for further consideration unless withdrawn in writing by you. The Formal Grievance Committee will have 30 days to review the grievance(s) and make its determination unless the grieving party and the Formal Grievance Committee mutually agree to an extension (documented in writing). If the grievance involves the collection of additional information outside the service area, the insurer or delegated entity will have 14 additional calendar days to render a determination. If you request, and wish to attend, a meeting can be held at a location within the service area convenient to you. The grievance will not be considered to be exhausted under any circumstances until completion of review by the Formal Grievance Committee or the conclusion of the additional 30-day time frame allowed for the review. We have implemented a procedure for an expedited process for the handling of urgent grievances as defined by AHCA. 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 time frame. In short, the condition must be life threatening in order to qualify as an urgent grievance. You must provide documentation from an authorized medical provider to support your request. In that documentation, it must be shown with substantial certainty that death or paralysis will occur within 72 hours if your request is not met. If your grievance falls under the definition of urgent, you shall be considered to have exhausted all managed-care grievance procedures after three days from receipt of the grievance. If the grievance is not deemed urgent by the primary care physician or medical care coordinator at the time of filing, the grievance process shall not be considered to be exhausted until conclusion of the standard grievance procedure. If a grievance is determined to be valid, appropriate corrective action will be initiated within seven days of the determination. 7

10 Review by the Grievance Committee is considered the final step in the employee grievance process. For additional information on rights and responsibilities and the dispute resolution process under Chapter 440, F.S., and related administrative rules, you are encouraged to contact the Employee Assistance Office of the Division of Workers Compensation in Tallahassee at You have the right to file a valid Petition for Benefits pursuant to Section , F.S., only after the entire grievance procedure has been exhausted. The Summit MCA may allow, but may not require, arbitration as part of the grievance process. A grievance arbitrated pursuant to Chapter 682, F.S., is permitted an additional time limitation not to exceed 210 calendar days from the date of the receipt of the request for arbitration. Responsibilities of the Summit MCA It is our responsibility to provide you with convenient access to medical care at a location close to your place of work. We will ensure that all medical services provided are performed by licensed, qualified providers. We will coordinate your return to work with your treating physician by obtaining a list of physical restrictions from your treating physician and forwarding it to your employer. If you have any complaints regarding your case, it is our responsibility to provide you with the information necessary to file a grievance. We will help you with questions about workers compensation and how to gain access to medical care. If, after contacting Summit, you have concerns which have not been resolved regarding this managed-care arrangement or the services provided through it, you may contact the Agency for Healthcare Administration Hotline ( ). 8

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12 HERITAGE SUMMIT HEALTHCARE LLC CORPORATE OFFICE Florida PO Box 3623 Lakeland, FL Fax SOUTHEAST REGION Georgia, Kentucky, North Carolina, South Carolina, Tennessee PO Box 600 Gainesville, GA Fax SOUTHWEST REGION Alabama, Arkansas, Louisiana, Mississippi, Texas PO Box Baton Rouge, LA Fax The following workers compensation payors lease and have access to the Heritage Summit HealthCare LLC preferred provider network: Bridgefield Casualty Insurance Company, Bridgefield Employers Insurance Company, BusinessFirst Insurance Company, Retailers Casualty Insurance Company and RetailFirst Insurance Company Summit Consulting LLC CC0330 REV 03/14 (12-055)