Document Sample
					FOR OFFICE USE ONLY                        APPLICATION FOR
FRAES FILE #                            WORKERS’ COMPENSATION
                                       MANAGED CARE ARRANGEMENT

Type of Application:
Initial Authorization                 Bi-annual Renewal of Authorization:    Service Area Addition/
                                      with changes                           Expansion Request
                                      without changes
                                                                             Amendment/change in the network or
                                      Authorization #                        plan of operation

Type of Insurer/Carrier:
Commercial Insurance Carrier                              Group Self Insured Fund
Assessable Mutual Insurer                                 Individual Self Insured Employer
Commercial Self Insured Fund                              Other

Legal Name of Applicant

Mailing Address

City                                 State                Zip                      Telephone Number

Contact Person                               Position Title                        Telephone Number

Proposed Service Area:
Region 1                Region 2              Region 3               Region 4                Region 6
Escambia                Bay                   Alachua                Baker                   Hardee
Santa Rosa              Holmes                Bradford               Clay                    Highlands
Okaloosa                Jackson               Citrus                 Duval                   Hillsborough
Walton                  Washington            Columbia               Flagler                 Manatee
                        Calhoun               Dixie                  Nassau                  Polk
                        Franklin              Gilchrist              St. Johns
                        Gadsden               Hamilton               Volusia
                        Gulf                  Hernando
                        Jefferson             Lafayette
                        Leon                  Lake
                        Liberty               Levy
                        Madison               Marion                 Region 5
                        Taylor                Putnam                 Pinellas
                        Wakulla               Sumter                 Pasco

Region 7                Region 8              Region 9               Region 10               Region 11
Brevard                 Charlotte             Indian River           Broward                 Dade
Orange                  Collier               Martin                                         Monroe
Osceola                 DeSoto                Okeechobee
Seminole                Glades                Palm Beach
                        Hendry                St. Lucie

AHCA Form 3160-0004, MARCH, 1997
Is there a capitated contract with providers or a network to provide health services?

                  YES                         NO
(If yes, attachment a copy of the capitated contract without the capitated amount)

Please provide information regarding which entities are performing the following services or functions of the WCMCA.
If the WCMCA is using more than one unique arrangement of contracted entities, please attach a separate table for each
distinct plan of operation.
TYPE OF SERVICE                    NAME OF LEGAL                 BUSINESS ADDRESS                    CONTACT AND
                                        ENTITY                                                  TELEPHONE NUMBER






GRIEVANCE/DISPUTE                                                                             Grievance Coordinator:

Does the WCMCA use a third party administrator (TPA) for any services other than those listed above such as bill payment, etc.?

                   YES                        NO
(If yes, please identify the TPA(s) and indicate the type of services provided.

AHCA Form 3160-0004, MARCH, 1997
III.   Application Filing Fee:
Amount Due: $1,000

(Checks should be made payable to Agency for Health Care Administration)

I certify the that I have been authorized by the governing body of the aforementioned insurer to file this
application and that the information contained herein is, to the best of my knowledge, correct and accurate.

                              Name (Please print)                              Title

                              Signature                                        date

AHCA Form 3160-0004, MARCH, 1997

Please attach a copy of the proposed managed care plan of operation for an initial application, addition to or amendment of
the originally approved plan of operation, or for a renewal application if the plan of operation is significantly different from
the original (e.g., a change in network provider arrangements, quality assurance, case management, utilization management,
or dispute resolution procedures or arrangements). The proposed managed care plan of operation must include:
1.        A summary or overview of the proposed plan of operation which indicates
         •      the organizational structure of the managed care arrangement;
         •      the proposed service area;
         •      the projected number of workers/employees in the service area to be served by the managed care arrangement
         •      the type of contracted arrangements available for providing covered health services;
         •      quality assurance activities to be conducted;
         •      the role of medical services coordinators in coordinating care and resolving workers’ concerns regarding care;
         •      activities related to the education of providers in workers’ compensation;
         •      activities related to the education of workers in how to access services and their rights and responsibilities
                under a workers’ compensation managed care arrangement.

2.       A statement or map providing a clear description of the service area or areas.

3.       A listing of health care providers included in the managed care arrangement by county, along with a copy of the
         signed contract between any provider network(s) or managed care organization and the insurer. The listing must
         include primary care physicians, specialists, hospitals, and ancillary services. A scale map of each service area
         indicating the general locations of primary care physicians or groups, specialists, and hospitals should be attached.

4.       A description of the grievance procedure to be used which addresses the following:.
         (a)       Procedures for hearing complaints and resolving written grievances from injured workers and health care
         providers. The procedures must be aimed at mutual agreement for settlement and may include arbitration
         (b)       The grievance procedure must be described in writing and provided to the affected workers and health care
         (c)       How, at the time the workers' compensation managed care arrangement is implemented, the insurer will
         provide detailed information to workers and health care providers describing how a grievance may be registered
         with the insurer.
         (d)       How grievances will be considered in a timely manner and will be transmitted to appropriate
         decisionmakers within the managed care arrangement who have the authority to fully investigate the issue and take
         corrective action.
         (e)       How if a grievance is found to be valid, corrective action will be taken promptly.
         (f)       How all concerned parties must be notified of the results of a grievance.
         (g)       The insurer must report annually, no later than March 31, to the agency regarding its grievance procedure
         activities for the prior calendar year. The report must be in a format prescribed by the agency and must contain the
         number of grievances filed in the past year and a summary of the subject, nature, and resolution of such grievances.

5.       A description of the quality assurance program which assures that the health care services provided to workers shall
         be rendered under reasonable standards of quality of care consistent with the prevailing standards of medical
         practice in the medical community. The program shall include, but not be limited to:
         a.        A written statement of goals and objectives that stresses health and return-to-work outcomes as the
         principal criteria for the evaluation of the quality of care rendered to injured workers.
         b.        A written statement describing how methodology has been incorporated into an ongoing system for
         monitoring of care that is individual case oriented and, when implemented, can provide interpretation and analysis
         of patterns of care rendered to individual patients by individual providers.
         c.        Written procedures for taking appropriate remedial action whenever, as determined under the quality
         assurance program, inappropriate or substandard services have been provided or services that should have been
         furnished have not been provided.
         d.        A written plan, which includes ongoing review, for providing review of physicians and other licensed
         medical providers.
         e.        Appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of

AHCA Form 3160-0004, MARCH, 1997
      f.       Adequate methods of peer review and utilization review. The utilization review process shall include a
      health care facilities precertification mechanism, including, but not limited to, all elective admissions and non
      emergency surgeries and should indicate the qualifications and ratio of utilization review personnel to workers or
      g.       Provisions for resolution of disputes arising between a health care provider and an insurer regarding
      reimbursements and utilization review.
      h.       Availability of a process for aggressive medical care coordination (case management), as well as a program
      involving cooperative efforts by the workers, the employer, and the workers' compensation managed care
      arrangement to promote early return to work for injured workers.
      I.       A process allowing employees to obtain one second medical opinion in the same specialty and within the
      provider network during the course of treatment for a work related injury.
      j.       A provision for the selection of a primary care provider by the employee from among primary providers in
      the provider network.
      k.       The written information proposed to be used by the insurer to comply with subparagraph h.
      l.       An affidavit certifying that the providers listed under item 3 have been credentialed and contracted by the

6.    Written procedures to provide the insurer with timely medical records and information including, but not limited to,
      work status, work restrictions, date of maximum medical improvement, permanent impairment ratings, and other
      information as required.

7.    Evidence that appropriate health care providers and administrative staff of the insurer's workers' compensation
      managed care arrangement have received training and education on the provisions of chapter 440 and the
      administrative rules that govern the provision of remedial treatment, care, and attendance of injured workers.

8.    Written procedures and methods to prevent inappropriate or excessive treatment.

9.    Written procedures and methods for the management of an injured workers’ medical care by a medical care
      coordinator including:
      (a)       The mechanism for assuring that covered employees receive all initial covered services from a primary care
      provider participating in the provider network, except for emergency care.
      (b)       The mechanism for assuring that all continuing covered services be received from the same primary care
      provider participating in the provider network that provided the initial covered services, except when services from
      another provider are authorized by the medical care coordinator pursuant to paragraph (d).
      (c)       The policies and procedures for allowing an employee one change to another provider within the same
      specialty and provider network as the authorized treating physician during the course of treatment for a work-related
      injury, if a request is made to the medical care coordinator by the employee; and requiring that special provision be
      made for more than one such referral through the arrangement's grievance procedures.
      (d)       The process for assuring that all referrals authorized by a medical care coordinator are made to the
      participating network providers, unless medically necessary treatment, care, and attendance are not available and
      accessible to the injured worker in the provider network.

10.   A description of the use of workers' compensation practice parameters for health care services when adopted by the

11.   A copy of informational materials to be provided to employees indicating the provisions, restrictions, and
      limitations of the workers' compensation managed care arrangement to affected workers, including at least:
      (a)      A description, including address and phone number, of the providers, including primary care physicians,
      specialty physicians, hospitals, and other providers.
      (b)      A description of coverage for emergency and urgently needed care provided within and outside the service
      (c)      A description of limitations on referrals.
      (d)      A description of the grievance procedure.

AHCA Form 3160-0004, MARCH, 1997
                                WCMCA APPLICATION INSTRUCTIONS

Applications for initial authorization or renewal of an authorization to provide workers’ compensation
services under a managed care arrangement should complete the application as specified under items I
through IV. below.

Applications for an addition or expansion of a service area or provider network for a previously
authorized managed care arrangement may file an application to amend the original application. For
expansions, the applicant is only required to file information on the provider network in the proposed
expansion counties and the proposed arrangements for quality assurance and medical services
coordination in these counties. For renewals or amendment of a previously authorized managed care
arrangement, the applicant is only required to file information relating to changes in the plan of
operation. An additional application filing fee is not required for amendments or changes to the plan of
operation or service area.

I.     Type of Application. Please place a check after the type of agency action which is being
       requested by the applicant.

II.    Type of Insurer. Please place a check after the type of workers’ compensation insurer which
       best describes the applicant. Organizations licensed through the Florida Department of
       Insurance should attach a copy of their currently valid certificate of authority.
       Applicant Information. List the legal corporate name of the applicant as registered with the
       Department of State.
       List the mailing address and telephone number of the applicant along with the name, position
       and phone number of the designated individual employed by or representing the applicant who
       will be responsible for responding to the agency on behalf of the applicant.
       Service Area. Place a check mark next to each county in which the applicant is requesting
       certification for a workers’ compensation managed care arrangement. Only check as many or as
       few counties as you wish to justify as having a comprehensive network of services. You are not
       required to provide a managed care arrangement in each county within a region.
       Service Arrangements. Indicate in the matrix or on an attached sheet information on those
       entities which are performing key functions for the WCMCA. For example, if the applicant has
       contracted with an HMO, EPO, PPO, PHO or other entity to provide a comprehensive network
       of health service providers, indicate the type of arrangement(s) and list the entity with whom the
       network arrangements have been made by the applicant. If the WCMCA is using more than one
       network, managed care organization, etc., attach a separate table or matrix for each distinct plan
       of operation in which the parties performing the functions differ. Attach a copy of the signed
       contract(s) with each managed care organization under contract and each HMO, EPO, PPO or
       other provider entity which has contracted directly with the insurer as the comprehensive
       network in an area. This does not apply to contracts with individual providers or multiple
       provider groups who are not serving as a comprehensive network. The name and telephone
       number of the individual who has been designated as the grievance coordinator for the
       arrangement must be included.

III.   For initial or renewal applications attach a check for $1,000 made out to the Agency for Health
       Care Administration.

AHCA Form 3160-0004, MARCH, 1997
IV.   Attachments

1.    Provide a summary of the applicant’s managed care arrangement(s) for providing health services
      to injured employees. If the applicant has more than one plan of operation (i.e., a variation of the
      original plan using different contracted entities) a description of how this differs should be
      included. The summary should explain how the network(s) would ensure access, provide and
      coordinate necessary health services to an injured worker. Include as an example a description
      of the activities which would occur from the time of injury to the workers’ return to work. In
      addition, the summary should address the following areas:
a.    the organizational structure of the WCMCA including the names and relationship of any entities
      which are performing delegated functions for the managed care arrangement;
b.    the proposed service area in which the managed care arrangement will be available to employers
      (you may refer to the map under item 2 below);
c.    the expected number of employees to be served in each county;
d.    the type of arrangements available in each network area for providing covered health services;
e.    provisions for educating providers on workers’ compensation goals and process, and roles and
      responsibilities in a managed care arrangement;
f.    provisions for educating employers and employees on workers’ compensation goals and process,
      and roles and responsibilities in a managed care arrangement;
g.    the types of quality assurance activities which will be carried out by the insurer to ensure the
      provision of high quality care and return the injured employee to work as quickly as is medically
h.    arrangements made to provide medical services coordination and how those services will
      function in coordinating care so as to return the injured employee to work as quickly as possible.

2.    Provide a map of Florida indicating those counties in which a managed care arrangement will be
      available to employers.

3.    Provide a listing of all health care providers which are either employed by or under contract with
      the applicant to provide health services under the managed care arrangement. This listing may
      be a copy of the materials which will be made available to employers and employees. The
      listing should indicate the name, address, telephone number and specialty of physicians and
      should be grouped by county or service area. For those applicants who are subcontracting with
      one or more managed care or other type of organizations for provider services, a copy of the
      signed contract(s) between a network or networks of providers and the insurer must be included.
      Also include a scale map(s) of each service area which shows the location of primary care
      physicians, specialty physicians, and hospitals. The boundary of the service area should be
      within 30 minutes average travel time for primary care physicians and hospitals and within 60
      minutes for specialty physicians.

4.    Provide a description of the insurer's grievance procedures for workers’ and providers of the
      managed care arrangement. These procedures must be consistent with Section 59A-23, F.A.C.
      Please include the name, address and phone number of the grievance coordinator.

AHCA Form 3160-0004, MARCH, 1997
5.    Provide a description of the quality assurance program which addresses each of the items listed
      under 5a. through 5k. of the Attachments section and the following areas: medical care
      coordination and case management, quality enhancement activities, peer review, utilization
      management, medical records review, and certification and recertification. For each network
      please indicate the type of financial arrangement between the insurer and provider for
      reimbursement of services. In addition, provide a signed affidavit certifying that providers have
      been credentialed and contracted.

6.    Explain how the network will ensure the reporting of management and other types of
      information from network providers to the insurer in order to meet oversight requirements of the

7.    Provide a copy of the plan for training appropriate providers and administrative staff in workers’
      compensation statute, rules to ensure that workers’ are returned to work as early as medically
      feasible. Training of health care providers may be satisfied by requiring certification training
      provided via an organization or individual which has been approved by the Division of Workers’
      Compensation. If an alternate method is used for training providers, such training must contain
      at least that information required for the certification training. The plan for training of
      administrative staff should address orientation of new employees, training of case management
      staff, and ongoing training regarding changes to the organization.

8.    Describe the arrangements for utilization management and peer review. The discussion of the
      utilization management program should address delegated and non-delegated activities; the
      process used to review and approve the provision of medical services, the qualifications of
      persons making pre-authorization and concurrent review decisions, how utilization review
      decision protocols or practice parameters are to be used. (This discussion may be included in the
      discussion of the quality assurance program under item 5).

9.    Describe the arrangements for aggressive medical care coordination of workers’ compensation
      injuries in order to return injured employees to work as soon as medically feasible. The
      description should address whether medical services coordination will be delegated or
      subcontracted (if subcontracted indicate the name and address of the entity which will provide
      the service), the duties and qualifications of the individuals performing medical services
      coordination, the expected ratio of staff to injured employees, and how medical services
      coordination will facilitate implementation of a medical care plan (This discussion may be
      included in the discussion of the quality assurance program under item 5).

10.   Describe how the managed care arrangement will adopt and incorporate practice parameters into
      the delivery of health services by network providers (May be included with the discussion of
      items 5 and 8).

11.   Provide copies of the informational materials which will be made available to employers and
      employees who are eligible to receive services through the managed care arrangement which
      describe the rights and responsibilities of employees including how to access to health services,
      changing primary care physicians, requesting a second opinion, the dispute/grievance resolution
      process, the telephone number for the grievance coordinator, the telephone number for the
      Employee Assistance Office of the Division of Workers’ Compensation, etc.

AHCA Form 3160-0004, MARCH, 1997
AHCA Form 3160-0004, MARCH, 1997