F
F
L
L
M
M
A
A
N
N
A
A
G
G
E
E
D
D
C
C
A
A
R
R
E
E
A
A
R
R
R
R
A
A
N
N
G
G
E
E
M
M
E
E
N
N
T
T
P
P
R
R
O
O
V
V
I
I
D
D
E
E
R
R
R
R
E
E
F
F
E
E
R
R
E
E
N
N
C
C
E
E
M
M
A
A
N
N
U
U
A
A
L
L
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
2
(Rev 1-12)
Provider Reference Guide
Pursuant to Rule (440 F.S. and 59A F.A.C.)
Introduction to Coventry Workers' Comp Services
With over 25 years of experience in the workers' compensation industry, Coventry
Workers' Comp Services ("Coventry") is a leader in cost and care management
services for workers' compensation insurance carriers, employers and third-party
administrators. Coventry offers a network of health care providers ("Coventry
Integrated Network") which consists of hospitals, physicians and ancillary providers. To
learn more, visit www.coventrywcs.com.
Being a participating provider in the Florida MCA increases the potential for channeling
patients to your practice because worker's compensation insureds must see a network
provider to receive maximum benefits.
Mission/Goal/Purpose
Coventry has created this "Provider Reference Manual" as one of several tools to
assist in understanding the provider's role and responsibility under the FL MCA
program and the 13 Provider Education guidelines (WC 52) Coventry and its
customers must manage to demonstrate compliance with Rule 440.134, F.S. and 59-
A23, F.A.C.
In addition, the Provider Reference Manual supplies valuable resources to assist
providers in the daily interactions with injured workers accessing the Coventry
Integrated Network.
While Coventry makes every effort to maintain accurate and up-to-date information, this
document is subject to change. Please check the Florida MCA Legislation requirements
for Chapter 440.134 workers’ compensation managed care arrangement at
http://www.leg.state.fl.us/Statutes.
Coventry’s Network for the MCA & Participating Providers
In the State of Florida, Coventry is an approved "Plan of Operations" for customers who
wish to participate in the FL MCA. One component of the MCA program is the Network.
The First Health and Focus Networks were combined on January 5, 2009 to form the
Coventry Integrated Network for the FL MCA. The Coventry Integrated Network used
for the Florida MCA program includes owned and leased/delegated arrangements
contracted through Coventry National, First Health and/or Focus Networks.
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
3
(Rev 1-12)
Compliance with Interpretive Guidelines
The following sections are in response to the requirements found under the State's
Interpretive Guidelines.
WC52 -SECTION A
Evidence that appropriate health care providers and Administrative Staff of the
payer's MCA program have received training and education.
Providers participating in the Florida WC MCA network must be Florida licensed and
WC certified. Information is located in the Provider Reference Manual, pages 4-8, 14
and 19.
Evidence that providers receive training and education that govern the
provision of remedial treatment, care, and attendance of injured workers.
Information is located in the Provider Reference Manual, pages 4-8, 14 and 19.
Provider Education - itemized section
1. The mission and goals of workers’ compensation managed care;
Information is located on the Coventry WC website, www.coventrywcs.com
. In
addition, it is found in this Florida MCA Reference Manual on pages 2 and 3.
2. Roles, Rights and Responsibilities
Information is located in this document under “the MCC role and responsibility of
the MCC and the PCP provider types” on pages 1-23.
3. Provider Network Procedures
Reference to provider network procedures are made throughout this Reference
Manual on pages 2, 3, 10-23 and include reference to Provider Education, Return to
Work, MCC, Referral practices and Case Management as noted under 440 F.S. and
59 F.A.C. Your Coventry contract, however, remains the same.
4. Case Management Procedures
The Provider Reference Manual, pages 3, 11, and 19, and the Coventry worker’s
compensation website, www.coventrywcs.com, include information on the Case
Management procedures.
5. Practice Guidelines
The Provider Reference Manual has reference to Practice Guidelines statutes and
regulations in the treatment of Florida injured workers on pages 3 and 13. In
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
4
(Rev 1-12)
addition, reference is made throughout this Reference Manual for Return to Work,
MCC, Referral practices and Case Management as noted under 440 F.S. and 59
F.A.C.
6. Utilization Management Procedures
The Provider Reference Manual on pages 4, 10 and 19 include information on UM
procedures.
7. Peer Review Procedures
Peer Review as a component of Coventry's Medical Chart Audits in noted on page
11.
8. Dispute Resolution and Grievance Procedures
The Provider Reference Manual, pages 16 and 17, includes information on the
dispute resolution and grievance procedures.
9. Communication Procedures between managed care components;
The State-Specific FL MCA reference Manual and the Employee Notice work in
tandem to let both the injured workers and providers know who/where to contact.
Should you have further questions regarding this program, please contact the toll
free number listed at the bottom of this page.
10. Medical records and case file procedures
Information is located in the Provider Reference Manual, pages 11-12 and 19-23.
11. Workers’ compensation managed care statutes and regulations relating
to remedial treatment and the statutes and regulations.
Reference to remedial treatment and the statutes and regulations are made
throughout this Reference Manual specifically on pages 3, 4 and 8 and include
reference to Provider Education as noted under 440 F.S. and 59 F.A.C., and the
AHCA interpretive guideline WC51. In addition, information is available on the bill
submission process as required under FAC Rule 38F-7.020. Amendments to Fla.
Stat. § 440.13 emphasizes the use of practice guidelines/parameters and protocols
as adopted by the U.S. Agency for Healthcare Research and Quality (AHRQ) in
effect as of January 1, 2003.
12. The health care provider’s role in successful return to work.
Information is located in the Provider Reference Manual, pages 3, 4, 11-13 and 18-
23. Notably, Senate Bill 50A requires certain standards of care in providing medical
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
5
(Rev 1-12)
care to injured workers. Your contract with Coventry, however, remains the same.
WC52 -SECTION B
13. The payer or delegated entity shall identify those physician & ancillary
providers who require training on the provisions of workers’ compensation
medical services and shall provide and document the staff training and
education program (59A-23.009(2) (a) (b), F.A.C.).
All providers that provide medical services for ill/injured workers must be certified.
This also includes the following "Ancillary" providers: PTs, OTs, DCs,
Acupuncturists, Naturopaths, Psychologists, Dentists (general and maxillofacial),
Home Health providers, etc. (Note - Facilities are "exempt" from the certification
requirements. Facilities are required to meet their specific facility type licensing and
credentialing directives)
WC 55 - PROVIDER NETWORK
A. The WCMCA shall be authorized to operate within a defined geographic
service area which may be a single or multiple counties. Each county
requested for authorization by the payer or its contracted entity will be
reviewed for compliance with minimum provider network requirements (see
AHCA Form # 3160-0005) and compliance with the 30/60 minute travel time
access requirements for medical services.
i. Average travel time in a geographic services area boundary to the nearest
general acute are hospital is no longer than 30 minutes under normal
circumstances.
Coventry has designed its MCA networks to support the 30-minute
requirement for the General Acute Care Hospital. This is confirmed in its semi-
annual submission to the State. Coventry’s MCA program, Coventry Integrated
Network, is certified in all 67 counties. In the event the state gave a waiver in
the county, injured workers would be able to seek care outside of the network
and the carrier or employer would agree to pay the provider’s fee for service in
conjunction with the Florida Provider Reimbursement manual.
ii. Average travel time in a geographic service area boundary to the nearest
specialty, ancillary services, specialty inpatient hospital services is no
longer than 60 minutes under normal circumstances. The agency shall
waive this requirement if the payer provides sufficient justification as to
why the average travel time is not feasible or necessary in a particular
geographic service area. 59A-23.003(7), F.A.C.
Coventry has designed its network to support the 60-minute requirement for
specialty, ancillary services and specialty inpatient hospital services. This is
confirmed in its semiannual submission to the State and the state’s response
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
6
(Rev 1-12)
letter. The Coventry Integrated Network is certified in all 67 counties. In the event
the state gave a waiver in the county, injured workers would be able to seek care
outside of the network and the carrier or employer would agree to pay the
provider’s fee for service in conjunction with the Florida Provider Reimbursement
manual.
B. The WCMCA shall establish a policy and procedure regarding timely access to
services which shall address access times for emergency, urgent, and routine
care including referral to specialty services and which reflects usual and
customary practices in the community. 440.134(5)
I. Emergency care is available 24 hours a day and 7 days a week.
Coventry has contracted with Hospitals and urgent care centers to make services
available 24/7. Additionally, within the Injured Worker’s Employee Notice, injured
workers are instructed to seek emergency treatment whenever necessary,
including after hours.
II. All required medical services are available and accessible;
The Coventry Integrated Network is certified in all 67 counties. In some counties,
the State has waived certain specialties because it is not available. In these
circumstances the injured worker may go outside the network and the
carrier/employer has agreed to pay the provider’s fee for services in conjunction
with the Florida Provider Reimbursement Manual.
III. Appropriate referrals are provided within the network;
Providers are contractually required to refer in network.
C. There are written agreements describing specific responsibilities for provision
of medical services. If the MCA’s responsibilities for the provision of medical
services are to be performed by another entity, then that arrangement must be
documented in a written agreement.
Coventry holds written agreements with its providers that define the responsibilities
of the Florida MCA. In addition, providers can access 24/7 the Provider Reference
Manual, that define the provider’s responsibilities, that can be accessed by either of
the websites located at the bottom of this page. Copies of Coventry agreements
(e.g. Coventry, First Health and Focus) have been submitted and approved by the
State.
The MCA also sends the injured worker communication within the Injured Worker
Employee Notice that defines the roles and responsibilities under the MCA. A
section of this Notice lists the services that require prior authorization and approval.
Copies of this communication have been submitted and approved by the State.
Coventry contracts with its customers including carriers, third-party administrators,
self-insured employers and other managed care entities. Copies of all agreements
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
7
(Rev 1-12)
have been submitted and approved by the State.
D. In the case of covered services, there are written agreements with providers
prohibiting such providers from billing or otherwise seeking reimbursement
from or recourse against any injured employee. 440.134(5), F.S.
Coventry’s contracts with its MCA providers include a provision which prohibits
billing or otherwise seeking reimbursement from or recourse against any injured
employee. Copies of these agreements have been submitted and approved by the
State.
E. An updated list of providers must be filed with the agency at least semi
annually. 440.134(13), F.S. The WCMCA shall file an updated Provider
Network directory listing by county by specialty with the Agency by January
1st and July 1st of each year in the state mandated format.
Coventry files semi-annually with the State the necessary documentation to
demonstrate adequate access by county and specialty. Upon approval, Coventry
delivers the information and approval letters to its customers.
F. The payer is responsible for the performance of all functions associated with
the delivery of compensable medical services to injured workers under
section 440.134, F.S., regardless of whether these functions have been
delegated via contract to other entities. If functions of the WCMCA have been
delegated by the payer to other entities, the WCMCA shall specify in contract
the oversight and reporting requirements for monitoring the performance of
these delegated functions. Reports of subcontractors shall be evaluated at
least quarterly, and the findings incorporated into the MCA’s quality
assurance program.
A copy of the credentialing policies and procedures has been filed and approved by
the State. Copies of the credentialing policies and procedures are available upon
request.
WC 56 - CREDENTIALING
A. Initial credentialing of all providers contracted to deliver patient care and
evidence of an ongoing credentialing process that is implemented at least
every two (2) years; 59A23.004(3)(b). F.A.C. AHCA (“Agency”) in February 2009
waived for all approved MCA’s the 2 year requirement to 3 years for the MCA’s
WC providers. The WCMCA shall have policy and procedure and implement a
process for credentialing and re-credentialing network providers at least every
three years. The credentialing criteria shall be specified in policy and shall
include verification of education of appropriate providers as required by
440.134(8), F.S. The re-credentialing process shall incorporate quality
assurance findings and complaints and grievances regarding individual
providers.
Florida Managed Care Arrangement (MCA)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
8
(Rev 1-12)
Coventry has credentialing providers participating in the FL MCA. Recredentialing
of workers’ compensation providers in Florida occurs at a minimum every 3 years.
Credentialing policies are available upon request. The process includes but is not
limited to: Primary verification of licenses, DEA, malpractice insurance, education
of appropriate providers and review of quality improvement findings and complaints
and grievances.
B. Evidence that appropriate health care providers and administrative staff of
the payer'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. 440.134(8), F.S.
Coventry has made its Provider Reference Manual available to all providers as
part of the education process for providers to define their role and responsibilities
under the Florida MCA. This manual is available 24/7 via the websites listed
below.
Coventry also supplies its customers with training materials about the Florida MCA.
Copies of these training materials have been submitted and approved by the State.
More information about training is found on page 7.
C. If the WCMCA delegates all or part of the credentialing process to other
organizations, the WCMCA shall specify the responsibilities of the contracted
entity and reporting requirements in the delegated credentialing agreement
and shall perform oversight of the delegated activities at least annually.
Reports on credentialing are reviewed quarterly within the Florida MCA QI meeting.
Clients, as the certified entity, have delegated the credentialing process to Coventry.
FL MCA QI meeting minutes are distributed to Coventry Florida MCA customers
quarterly to support over sight.
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
9
(Rev 1-12)
Below is important information for the provider to assist in understanding the role and
responsibility under the FL MCA and about participation in the Coventry Integrated
Network
BACKGROUND
Coventry’s MCA is enacted by Section 440.134 Florida Statutes to assist workers’
compensation payers in controlling health care costs while maintaining quality medical
standards. Network providers are qualified health care professionals who have met
stringent credentialing standards and are approved to participate in the Florida MCA.
The Florida MCA increases the potential for channeling patients to your practice
because worker’s compensation insureds must see a network provider to receive
maximum benefits.
The Florida MCA Legislation is a voluntary program for employers or their payers, who
provide workers’ compensation. The Florida MCA requires certification by the state
which we received in January 1997. Additionally, the Florida issued the Health Care
Provider Certification Rule, which became effective March 14, 1995. State law requires
that all physicians providing workers’ compensation medical services must be certified
and educated on the Program in order to provide these services and be eligible for
payment.
On July 15, 2003, Gov. Bush of Florida signed into law Senate Bill 50A. The new law
became effective on October 1, 2003. Amendments to Fla. Stat. § 440.13 emphasizes
the use of practice guidelines/parameters and protocols as adopted by the U.S.
Agency for Healthcare Research and Quality in effect as of January 1, 2003. (U.S.
Agency for Healthcare Research and Quality will henceforth be referred to as AHRQ.).
In 2007, AHCA (“Agency”) made an internal process change in 2007 that allowed
Managed Care Arrangements (MCA) to waive the mandated 2 year credentialing and
recredentialing requirements to 3 years for WC providers as long as they are NCQA,
JACHO and URAC accredited. And in February 2009, the Agency expanded the
waiver to include all MCA's, regardless of accreditation status, to waive the 2 year
requirements. In addition, the Agency determined that an MCA is not required to
mandate WC provider certification or is required to retain proof of WC certification in
provider files. But still require such practice to be embedded in MCA’s credentialing
and recredentialing policy and procedures.
MCA CERTIFICATION
The carrier or self-insured employer must become the FL MCA certified entity. Coventry
offers two types of services under the FL MCA:
Fully Bundled - The carrier or self-insured employer is the certified entity and uses
Coventry's approved "Plan of Operations" to support the required components of the
FL MCA.
Network Only - The carrier or self-insured employer is the certified entity and solely
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
10
(Rev 1-12)
uses the Coventry Integrated Network for their program. All other elements of the
FL MCA Plan of Operations are supported by the certified entity or its selected
vendors.
For a comprehensive list of certified FL MCA customers using the Coventry Integrated
Network for their certified program, go to the Coventry website noted below. Select
Provider Services and look at the specific FL page for a list of Coventry FL MCA
customers.
NETWORK APPROVAL
Coventry’s MCA is currently certified in all 67 counties. Some counties have provider
specialties that are not available and where the state has granted an exception/waiver.
Injured Workers may seek care with non-network providers when the State has
approved county or specialty waivers. The carrier agrees in these circumstances to
approve care with these non-network providers and pay services at the Provider's fee
for services in conjunction with the Florida Fee for Service Reimbursement Manual.
REFERRAL MANAGEMENT
Per Florida state law, providers must obtain prior approval from the carrier to refer a
injured worker to another primary care physician (PCP) or specialty care provider.
Our payers, in conjunction with state law, mandate that before treatment, the
following services need prior authorization:
• Referral to another primary care physician (PCP) or specialist
• Admission to a hospital (acute rehabilitation Coventry contract hospital)
• Surgery
• Ancillary care (except for routine laboratory and x-rays)
• Attendant Care: Under Senate Bill 50A, attendant care is only available with a
written prescription from the physician. Such prescriptions must outline time periods
for the attendant care, level of required and type of assistance required. SB 50A also
outlines reimbursement for family members providing attendant care.
Some payers require that all services be certified through their utilization
management (UM) program prior to treatment. Please refer to your Comprehensive
Client List to contact the payer directly with questions regarding utilization
management certification.
Once you see an injured worker, please be sure to immediately call the referral
telephone number for each individual MCA payer noted in your Comprehensive Client
List (use the number in the UM/pre-certification column) or the Employee Notice. This
will assist you with program compliance.
*Remember: All referrals should be made to other Coventry Florida MCA contracted
providers whenever possible. Coventry Florida MCA directory can be accessed
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
11
(Rev 1-12)
through our website www.coventrywcs.com
CASE MANAGEMENT
When injuries or illnesses occur, a Case Manager may be assigned. The Case
Manager’s role will be to work with all parties to assist in the coordination of the medical
and return-to-work challenges presented by the participants.
MEDICAL CHART & PEER REVIEW AUDITS
As an approved FL MCA Plan of Operations, Coventry is required to conduct Medical
Chart & Peer Review Audits to confirm providers are adhering to State required
Treatment standards and Practice Guidelines. Coventry randomly selects FL Network
providers who have rendered services to injured workers during the last year. Coventry
requests their medical records in order to conduct an audit of the documentation. Once
received, Coventry's Quality Improvement medical staff audits the charts for
compliance. Findings are communicated to the Coventry FL MCA Quality Improvement
Committee and Corporate Workers’ Comp Quality Improvement Committee. Coventry
sends educational letters to the providers advising them of the missing components.
Depending on the severity of the missing component, Coventry may submit the medical
records for peer review by a medical director. Providers are notified either in writing or
telephonically of adverse peer review findings outlining needed corrective action.
It is important to check your Medical Charts. Coventry has found over the last 10 years
that providers frequently miss the following:
Sending timely reports to payers
keeping medical notations consistent from one record to another
Checking Medical Records to make sure key elements are completed
Documenting known allergies or checking for drug interactions
REQUESTS FOR PRE- PAYMENT
It is important to note that requests for prepayment are not appropriate in Florida. Most
of the billing codes are defined under the FL Reimbursement Manual. In addition, the
FL WC health care delivery system requires a provider to bill rendered services for
reimbursement as defined under section 440.13(3) and (4), Florida Statutes.
Specifically, providers may not, due to nonpayment of moneys by the MCA, insolvency
of the MCA, or breach of the agreement, bill, charge, collect a deposit, seek
compensation, remuneration, or reimbursement from, or have any recourse against the
subscriber, dependent of subscriber, enrollee, or any persons acting on their behalf, for
services provided in the treatment of a workers’ compensation illness or injury.
Providers may be subject to fines or penalties as described under Florida Rule FL 69L-
34.001 for non-compliance with the Workers' Compensation Act and Division rules for:
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
12
(Rev 1-12)
Failing to submit medical records and reports;
Failing to refund an overpayment of reimbursement;
Collecting or receiving payment from an injured worker in violation of the Workers’
Compensation Act;
Failing to follow standards of care, including overutilization of services; or
Failing to properly bill medical services which means failing to comply with the
Division's billing and reporting requirements and the applicable reimbursement
manual(s).
**Note - Recommending treatment that would constitute overutilization, in and of itself,
is not an instance of overutilization.
PRIMARY CARE PROVIDERS
Primary Care Providers (PCP) manage the overall treatment plan of the injured
workers. PCPs are defined as practicing in at least one of the following disciplines:
MEDICAL CARE COORDINATOR (MCC)
The Medical Care Coordinator (MCC) must be a primary care physician. Section
440.134, states "Medical Care Coordinator means a primary care provider within a
provider network who is responsible for managing the medical care of an injured
worker. A medical care coordinator shall be a physician licensed under chapter 458
or an osteopath licensed under chapter 459.Those physician types licensed under
chapter 458 or chapter 459, F.S., which are allowed by the agency to be primary
care providers may also be designated as a Medical Care Coordinator.”
The MCC's role includes facilitating referral authorizations for evaluation and/or
treatment provided by other health care professionals/facilities. MCCs are also
responsible for responding to requests for disability ratings. Other key qualifications
are that they participate in the Coventry Integrated Network and have either M.D. or
D.O. credentials (physician specialties other than Family Practice, General Practice
or Internal Medicine may be utilized as an MCC based on the individual treatment
needs of the injured worker). Licensed chiropractors and podiatrists can also be
‘medical care coordinators as of October 1, 2003. (SB50A amended Fla. Stat. §
440.134).
In some instances, the MCC may also be the Primary Care Physician that initially
treats the injured worker.
PRIMARY CARE PHYSICIAN
A Primary Care Physician (PCP) is defined as being the initial treating physician.
The PCP is responsible for the continued care of injured workers once specialist
services have been completed. PCPs include the following specialty types: Internal
Medicine, Family/General Practice, Chiropractic Medicine, Occupational Medicine
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
13
(Rev 1-12)
and Urgent Care. (Other specialty physicians may be designated as PCPs based on
the individual needs of the injured worker).
CHIROPRACTOR TREATMENT
Chiropractic treatment limits were increased to 24 treatments (up from 18) or
rendered 12 weeks (up from 8 weeks), whichever comes first. (SB50A amended Fla.
Stat. § 440.134).
MEDICAL RECORD STANDARD
Maintaining medical records should be handled in a manner consistent with
professional medical record-keeping guidelines. This means that patient records are
legible, complete, accurate, and easily retrievable. Additionally, the handling of these
records should be done in such a manner to protect the confidentiality of the patient.
Whenever possible and if requested, providers must provide patient data electronically
to the State.
Medical records should include significant procedures, past and current diagnosis, and
patient demographics (i.e. patient name, employer name, date of birth, etc).
Additionally, documentation for each visit should include the following:
Chief complaint
Therapies administered/prescribed
Providers signature/initials/
Objective findings of Practitioner
Studies Ordered (i.e. labs, x-rays)
Diagnosis or Medical Impressions
Name and profession of practitioner
PRACTICE GUIDELINES
Florida statutes § 440.13 emphasizes the use of practice guidelines/parameters and
protocols as adopted by the U.S. Agency for Healthcare Research and Quality in effect
as of January 1, 2003. (U.S. Agency for Healthcare Research and Quality will
henceforth be referred to as AHRQ.)
Referrals to specialists must be consistent with practice parameters. Compliance with
practice parameters is an explicit objective of utilization review and provider audits.
Providers that deviate from practice parameters risk their authorization from the state to
treat injured workers. Carriers have an obligation to report to AHCA any determination it
makes that treatment provided is “in excess of” adopted practice parameters. The
AHRQ maintains a clearinghouse of practice protocols at www.guidelines.gov.
CHANGE OF PROVIDERS
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
14
(Rev 1-12)
An injured worker is allowed one change to another provider within the same
specialty and provider network as the authorized treating physician during the course
of treatment in a work related injury.
CONTINUITY OF CARE
All continuing care must be received from the same Primary Care Network provider that
supplied initial covered services, except when services from another provider are
authorized by the medical care coordinator.
OUT OF NETWORK REFERRALS
An injured worker may see a non-network provider under the following circumstances:
For any emergencies;
When services from another provider are authorized by the MCC;
When authorized by the carrier prior to the treatment date;
When the state has waived county or specialty access.
Under these circumstances, the carrier will pay the provider's fee for services according
to the FL Fee Reimbursement Manual.
REQUESTS FOR INDEPENDENT MEDICAL EXAMS (IME)
Under 440.13(5), an injured worker may have one IME per accident. Costs for the IME
will be paid by the carrier if performed by a physician in the Network. Otherwise, such
costs shall be paid in accordance with 440.13(5). An IME requested by a claimant and
paid for by the carrier shall constitute the claimant's one IME per accident.
TRAINING & EDUCATION
As part of the FL MCA program, the MCA is required to present training and education
to staff, providers and injured workers. Coventry accomplishes this in multiple ways:
PROVIDERS:
Coventry supplies this Reference Manual at the time of joining the Network and via
the website at www.coventrywcs.com to define how the MCA program works. In
addition, Coventry sends provider communications periodically about changes in the
program or other key items that affect providers. Finally, Coventry has staff within
WC Provider Services and Network Operations who are responsible for managing
the daily activities with providers including support for contractual questions,
assistance with understanding the program and assistance with resolving issues
pertaining to the program, clients or reimbursement.
CLIENTS:
Key Florida MCA Program Elements
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
15
(Rev 1-12)
Coventry supplies prospective and current clients with educational materials
about how the FL MCA program works via a presentation, implementation
meeting and client bulletins. Samples of these materials are available upon
request.
INJURED WORKERS:
Carriers and employers supply communication to employees at the time an
employer joins the FL MCA and an Employee Notice to injured workers at the time
of injury to assist the injured worker in understanding the roles and responsibilities of
the FL MCA. Samples of these materials are available upon request.
COVENTRY EMPLOYEES:
Educational materials about how the FL MCA program works are reviewed with
Coventry employees within Network Operations, Provider Services, Client Services,
Clinical Management (TCM/UM), Quality Improvement (QI), Credentialing, Network
Management, Compliancy, Legal, MCO Product Development and any other
department responsible for managing the daily activities with injured workers,
providers, and clients.
Complaints & Grievances
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
16
(Rev 1-12)
COMPLAINTS AND OTHER ISSUES
Complaints are defined by the State as any dissatisfaction concerning the MCA,
initiated by, about or on behalf of an injured worker's medical care as defined under
Section 440.134. Coventry reviews and resolves complaints within 10 days of receipt of
the complaint, unless all affected parties, including but not limited to, the injured worker,
complainant (if other than the injured worker), provider and the certified/delegated entity
mutually agree to an extension. Written notification is provided to all affected parties of
the right to file a grievance when a complaint remains unresolved more than 10
calendars days after receipt.
All other issues (not involving the injured worker) are not classified as a complaint.
Coventry will receive and resolve these issues within 30 days.
WRITTEN GRIEVANCE (REQUIREMENTS & PROCESS)
Coventry’s Grievance Procedure is available to any participating provider, injured
worker, carrier, or third-party administrator (“TPA”). Below is a summary of the
requirements for filing a grievance. A copy of the full policy and procedure for
grievances is available upon request.
Coventry will address employer and employee grievances as applicable to Coventry
and when appropriate, assist in redirecting the inquiry to the certified MCA.
Pursuant to the state’s definition of a grievance, Coventry does not consider the
following items as grievances:
Indemnity benefits;
Vocational benefits;
Maximum medical improvement;
Impairment;
Medical mileage reimbursement;
Provider payments;
Attorney’s costs and fees;
Compensability;
Causation.
If a provider wishes to file a grievance, the provider must complete the grievance form
(AHCA Form 3160-0019). Upon request, Coventry will provide this AHCA Form 3160-
0019 within 7 days. Providers should send the form directly to the certified FL MCA
entity.
For grievances involving the Coventry FL MCA program or the Coventry Integrated
Network, send the grievance form to Coventry Grievance Coordinator, Quality
Complaints & Grievances
For any questions regarding the MCA program, please see Coventry WC website
Improvement, 3200 Highland Ave., Downers Grove, IL 60515.
Coventry's Grievance Coordinator is accessible by calling 800-262-6122. The toll-
free telephone number provides reasonable access to the Grievance
Coordinator without undue delays. This telephone number is routinely
provided to the provider/carrier/TPA via Client Communication. Providers are given
this information through Provider Updates, Provider Manuals, and through any
written correspondence regarding the grievance.
W
ritten grievances will be resolved within the following time frames:
1
• Expedited Grievances – An expedited grievance procedure is available to any
participating provider, carrier, or TPA. Coventry will resolve urgent grievances within
3 calendar days of receipt. Coventry defines an urgent grievance as a matter where
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. A grievance initiator will be considered to have exhausted all
managed care grievance procedures after 3 days from receipt.
• Standard Grievances – For standard grievances, there will be a consultation with
the appropriate parties and Coventry will render a determination on the grievance
within the 14 allotted calendar days of initial receipt of the grievance.
For determinations not in favor of the aggrieved party, the grievance coordinator will
advise the aggrieved party that the issue will be sent to the grievance committee unless
withdrawn in writing by the griever. This Grievance Committee is composed of three
individuals, including a physician who is licensed in Florida and has professional
expertise relevant to the issue. The committee must render a decision within 30 days,
unless all parties mutually agree to an extension and documents that communication in
writing.
If the grievance involves collection of additional information outside the service area,
an additional 14 calendar days will be allowed to render a determination. Coventry
will notify the griever of the need for additional information in writing within 7 days of
receipt of the grievance by the Grievance Committee.
If supportive documentation is not received from the griever within the required
timeframe, Coventry will terminate the grievance. The grievance can be reopened
should the supportive documentation become available. Providers who are non-
responsive to requests for information within the grievance process are removed from
the network.
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
17
(Rev 1-12)
1
This period may be extended if delays occur as a result of Coventry’s inability to obtain appropriate
documents or records necessary to reach a decision on the grievance; or by written agreement between
Coventry and the griever.
Complaints & Grievances
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
18
(Rev 1-12)
The griever will be considered to have exhausted all managed care grievance
procedures if a determination has not been rendered within the required timeframe or
other timeframe, as agreed to the parties in writing.
A full copy of the grievance procedure and a copy of the Grievance Form are
available upon request by calling Coventry's Grievance Coordinator noted above or
Coventry's toll-free Provider Services number noted below.
Frequently Asked Questions (FAQs)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
19
(Rev 1-12)
What is the FL Workers' Compensation Managed Care Arrangement (MCA)?
Florida’s MCA is enacted by Section 440.134 Florida Statutes to assist workers’
compensation payers in controlling health care costs while maintaining quality medical
standards. Network providers meet stringent quality criteria and are qualified health
care professionals. The Florida MCA increases the potential for channeling patients to
your practice because workers’ compensation insureds must see a network provider to
receive maximum benefits.
Am I a participating provider in the FL MCA?
Yes. As a contracted Coventry provider, you are part of the MCA because you have
agreed to serve workers’ compensation patients.
Is the FL MCA Currently Active?
Yes. In your Comprehensive Client List you will receive notice of which clients are
effective. Currently, the Coventry Integrated Network is approved in all 67 counties.
Is certification required to treat workers' compensation injured workers under
the FL MCA?
Yes. The state of Florida issued the health provider Certification Rule (440.13(1), F.S.),
which became effective March 14, 1995. This rule establishes the process whereby
health care providers are educated and informed about the Florida MCA in order to
receive payment for treating work-injured employees.
In relation to my current contract with Coventry, what will I need to do
differently for insureds participating in the FL MCA?
The only difference is that you must call a toll-free referral line whenever referring an
insured patient of an MCA payer to another provider.
What are the services that require approval or precertification for care or
referrals to specialists?
Per Florida state law, you must obtain prior approval if you need to refer a patient to
another PCP or specialty care provider. Our payers, in conjunction with state law,
mandate that the following services require prior authorization:*
• Referral to a specialist or new PCP
• Admission to a hospital (acute or rehabilitation contract hospital)
• Surgery
• Ancillary care (except for routine laboratory and x-rays)
• Attendant Care: Under Senate Bill 50A, attendant care is only available with a
written prescription from the physician. Such prescriptions must outline time periods
for the attendant care, level of required and type of assistance required. SB 50A also
outlines reimbursement for family members providing attendant care.
*Some payers require that all services be certified through their utilization
management program prior to treatment. Please contact the payer directly with
Frequently Asked Questions (FAQs)
For any questions regarding the MCA program, please see Coventry WC website
questions regarding Utilization Management certification of services.
Our MCA payers require that injured workers use primary care physicians in the
Coventry Integrated Network. Once you see an injured worker, please be
sure to immediately call the referral telephone number for each individual
MCA payer noted in the Comprehensive Client List or the Employee Notice. This will
confirm program compliance. During the call, you will be asked to provide information
on the injured worker’s current medical status, return-to-work status, and treatment
plan.
What are my contractual requirements?
• Provide workers’ compensation services with a return-to-work focus
• Accept the contract rate as payment in full
• Work with our clients’ utilization management programs (call to initiate review after
the patient’s first visit and return utilization and medical management calls)
• Comply with requests for patient records
• Whenever possible, providers must provide patient data electronically to the State
when requested.
• Refer to other network providers when available
What does it mean to provide care with a "Return-To-Work" focus?
All treatment proposed and rendered is focused on preparing the injured worker to
return to productivity as soon as medically feasible. Treatment plans require active
involvement of the provider, injured worker, employer, adjuster and case manager from
initiation of treatment through release-to-work and/or settlement. Treatment plans
should be practical and implementable. “Reasonable necessary medical care” must:
• Utilize a high intensity, short duration treatment
• Include treatment plan reassessment every 30 days; and
• Focus on treatment of specific clinical dysfunction and not be based on “nondescript
diagnostic labels” (SB50A amended Fla. Stat. § 440.134).
Throughout the process, it should be emphasized to the injured worker that the intent of
treatment is to allow them to return to the worksite in some capacity. This may include
modified duty for a period of time, as soon as they are medically able to do so. Clear
communication of the treatment plan, including anticipated time frames to all involved
parties, is essential to reaching the treatment goals.
Are there requirements on how soon I will need to see an injured worker when
they call for an appointment?
Since these injured workers often require your approval to return to work, please use
your best efforts to schedule their initial and consecutive appointments within 48 hours
of first contact. Additional lost-time wages and additional medical costs will be avoided
by examining and returning a patient to work as soon as possible.
What is the definition and role of Medical Care Coordinator (MCC)?
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
20
(Rev 1-12)
Frequently Asked Questions (FAQs)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
21
(Rev 1-12)
• Manages the medical care of injured workers including referrals to other health care
providers/facilities where the injured worker will be referred for evaluation or
treatment.
• Primary Care Provider participating in the Coventry Integrated Network
• Physicians credentialed as M.D. or D.O.
• Physician Specialties other than Family Practice, General Practice and Internal
Medicine may be utilized as an MCC based on the individual treatment needs of the
injured worker
• Licensed chiropractors and podiatrists participating in the Coventry Integrated
Network (SB50A amended Fla. Stat. § 440.134).
• Responds to request for disability ratings
What provider types are considered MCA Primary Care Physicians (PCPs) by
Coventry?
Florida MCA PCP specialty types include: Internal Medicine, Family/General
Practice, Occupational Medicine, Urgent Care Physicians/Facilities and
Chiropractic Medicine, Other Specialty Physicians may be designated as PCPs
based on individual treatment needs of the injured worker.
Does prior certification on medical services guarantee payment?
No, compensation remains within the sole discretion of the workers’ compensation
payer. However, lack of prior certification can result in non-payment for non-emergency
services under the law.
Whom do I call with payment and bill submission questions?
Billing and bill submission information can be obtained by calling the injured worker’s
employer.
For AETNA related bill submission questions, direct your questions to AETNA at
(800) 238-6288. Additional AETNA provider educational information can be found
at their website:
http://awca.aetna.com/AWCA/ihtAWCA/r.WSIHW000/st.36443/t.75943.html
Where do I submit claims?
For the proper claims submission address, please contact the injured worker’s
employer.
What information do I need to submit with a claim?
In accordance with FAC Rule 69L-7.602, providers must submit office notes with each
date of services billed (unless the carrier specifies otherwise). A complete report must
be submitted within 15 days of the initial visit and within 21 days (upon a carrier’s
request) for all follow-up visits. This information is also located in the 2000 Florida
Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual.
How will the injured worker know how to find my practice?
Frequently Asked Questions (FAQs)
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
22
(Rev 1-12)
We work closely with our payers to produce employer educational materials, such as
work-site posters, to help channel injured workers to your office. In most cases, an
injured worker will receive an Employee Notice from their employer prior to seeking
medical care.
Note: To ensure that our directory includes current demographic information regarding
your medical practice, please contact your Provider Services Department 800 number
listed at the bottom of this page to verify this information.
What are the benefits to participating?
While Florida's workers' compensation MCA is no longer mandated, providers
participating in an MCA will benefit from increased patient channeling through:
• Referral management
• A select network of physicians providing workers’ compensation services
• Injured worker education
• Employer referrals to network providers
When Should I contact Coventry's Provider Services?
Call Provider Services' toll-free number listed at the bottom of this page for issues
concerning:
• Network participation status
• Patient identification
• Payment status
• Other administrative/program issues
• Provider reimbursement
(Please note: Selected contract interpretation issues, including contract rates, may be
referred to our Florida Network Operations team for resolution.)
A WC Provider Services Specialist will obtain a description of the problem and gather
necessary supporting documentation. Issues unresolved at the specialist level are
reviewed by the WC Provider Services supervisor. The WC Provider Services
supervisor will continue to clarify and define the scope of the problem and communicate
the issues to affected departments within the company and the provider. The supervisor
will also set and communicate expected resolution time-frames.
AETNA (AWCA) Information
For any questions regarding the MCA program, please see Coventry WC website
www.coventrywcs.com Or call WC Provider Services @
(800)937-6824
23
(Rev 1-12)
Whom do I call with AETNA contract questions?
AETNA related contract questions should be directed to:
1. If you have questions about the rate comparison process, please call 1-800-
AETNA88 (2386288) or email [email protected] or write to: Aetna,
Inc. 151 Farmington Avenue Mail Stop RT 62, Hartford, CT 06156 Attention:
Provider Relations Unit
2. If you have any other questions regarding Aetna/ AWCA in general, please call us at
1800-AETNA06 (238-6206) Additional AETNA provider educational information
specific to Florida MCA can be found at their website:
http://awca.aetna.com/AWCA/ihtAWCA/r.WSIHW000/st.36443/t.75943.html
(While Coventry makes every effort to maintain accurate and up-to-date
information, some information in this document is subject to change. Please check
your Florida MCA Legislation requirements.)
