managed care guide · 2018. 11. 9. · the heritage summit managed-care arrangement (mca) is...

for your workers’ compensation injury or illness

Managed Care Guide

FLORIDAProvided through Heritage Summit HealthCare, a Summit subsidiary

www.summitholdings.com | 1

Navigating Your Medical CareWe are sorry to learn about your accident at work and want you to know that the people at Summit are here to help. Sometimes a work injury—especially one where you lose time from your job—can be difficult for you and your family. Whether you’re dealing with a minor wound or a major injury, our goal is to guide you through the process so that you can get back to work.

Please read through this Managed Care Guide to help you become familiar with the workers’ compensation insurance medical-care process. Feel free to call your adjustor at any time with questions about this material or your recovery process. (Please note that, due to legal requirements, we may occasionally refer to your adjustor as your medical services coordinator. The terms “adjustor” and “medical services coordinator” refer to the same person. (See page 3.)

If you have any questions as you work through your injury and recovery, please be sure to call us.

Important contactsAs you go through the claims process, you may find it helpful to record the names and numbers of your contacts here.

Summit Claims Center PO Box 2928Lakeland, FL 33806-2928Main line 863-665-6629 Toll free 1-800-282-7644

My Summit adjustor

My primary physician

My other physician(s)

My nurse case manager (if applicable)

My pharmacy

Agency for Health Care Administration Hotline (AHCA) 1-800-226-1062

This Managed Care Guide provides you with information about our managed care arrangement. The guide is subject to our Florida Workers’ Compensation Managed Care Arrangement Plan of Operation filed with and approved by the Florida Agency for Health Care Administration (AHCA); and is provided in accordance with Fla. Stat. Ann. sections 440.13 & 440.134 (West 2017); and Fla. Admin. Code r. 59A-23.001, et seq. (2017).

2 | www.summitholdings.com

Terms to Know and Understand ............................................................................3

Our Responsibilities ...................................................................................................... 4

Your Medical Rights and Benefits Ongoing medical care ....................................................................................................4 Referrals ........................................................................................................................... 5 Second opinions ............................................................................................................. 5 Surgery or hospitalization ............................................................................................ 5 Changing physicians ...................................................................................................... 5 Independent medical evaluations ...............................................................................6 Document copies ............................................................................................................6 Prescriptions ...................................................................................................................6

Prescription ID card ................................................................................................6 Out of network ........................................................................................................6 Reimbursement ....................................................................................................... 7

Medical bills ..................................................................................................................... 7

Your Responsibilities Medical appointments ...................................................................................................8 Drug or alcohol testing ..................................................................................................8 Returning to work ..........................................................................................................8

Requests, Complaints and Grievance Procedures Initial requests for medical services and changes ..................................................9Complaints ......................................................................................................................9Grievances ..................................................................................................................... 10

How to file a grievance ........................................................................................ 10 The standard grievance procedure ................................................................... 10 Urgent grievances .................................................................................................. 11 Additional grievance information ....................................................................... 11

Explanation of Corporate Relationships ........................................................ 12

Workers’ Compensation Fraud Notice ............................................................. 12

Table of Contents


Terms to Know and Understand What is workers’ compensation?Workers’ compensation is insurance that most businesses are required to have to protect their employees in the event of work-related injuries or illnesses. This means that, if you are injured on the job or become ill, the insurance company pays for your authorized medical expenses and a portion of your lost wages. Your benefits are regulated by the state of Florida and are set by statutes and case law.

Who are we?Summit. Summit is the company that manages your employer’s workers’ compensation insurance program. We’re one of the largest providers of workers’ comp insurance services in the southeastern United States, and have been handling worker injuries for more than 40 years. Most of the communication you receive about your injury will come from us.

Heritage Summit HealthCare LLC. Heritage Summit HealthCare LLC is a subsidiary of Summit. Heritage operates our provider network and our managed-care arrangement (MCA) for injured workers in Florida.

What is managed care?Managed care means that Heritage Summit has entered into agreements with health-care providers to provide and manage appropriate remedial medical treatment for you, and includes both in-network and out-of-network providers. In other words, your provider will decide whether you need to return for additional treatment, see a specialist, have physical therapy, etc.

The Heritage Summit managed-care arrangement (MCA) is designed to provide you with quality medical care for your work injury or illness. Our MCA works with you, your employer and your authorized health-care provider to ensure that you receive appropriate medical treatment so that you can return to work as soon as medically possible.

What’s the difference between an adjustor and a medical services coordinator? For your work-related injury, you will interact with a Summit adjustor, who will coordinate your medical services, and act as your medical services coordinator. The terms refer to the same person.


Our ResponsibilitiesIt is our responsibility to provide you with convenient access to medical care at a location close to your home or workplace. We will ensure that all medical services provided are performed by licensed, qualified health-care providers.

Your adjustor will help you with questions about how workers’ compensation works, explain how to access your medical care, and coordinate your return to work with your physician and your employer. During this process, your physician will communicate any work restrictions directly to us, you and to your employer.

If you are dissatisfied with your medical care, you may file a grievance with us. Be sure to refer to the Request, Complaints and Grievances Procedures section on pages 9 through 11 of this guide.

We are required to send various forms to the State of Florida Office of Insurance Regulation, and we must provide you with copies of each as they occur. If you have any questions about any of these state forms, please be sure to contact your Summit adjustor.

Your Medical Rights and BenefitsYour employer purchased Florida workers’ compensation insurance coverage that covers you and your fellow employees. From your first day of work, this coverage is in place to pay for medically necessary remedial medical treatment for injuries or illnesses related to your

employment, at no additional cost to you. Medical care includes approved physician, surgical, hospital and dental care, ancillary services (radiology, durable medical equipment, physical therapy, etc.), as well as prescriptions and medical supplies.

Ongoing medical careGenerally, you must use health-care providers in our network for ongoing medical care for your work-related injury or illness, and we must provide authorization prior to your treatment. If a network treatment facility near your worksite is available to provide you with medical care, you should go there unless it is an emergency or unless you are told otherwise by us. 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; if not, we will authorize treatment with a nonnetwork health-care provider.

Your adjustor will help you identify and choose the appropriate providers and will give them the necessary authorizations. You may also view our complete provider directory on our website, www.summitholdings.com.

It is important for you to know that any ongoing medical treatment you receive outside of our network, other than a true life- or limb-threatening emergency, is generally not covered unless we authorize it.


ReferralsYour authorized physician may refer you to another physician or specialist, if needed. The other physician or specialist will consult with your adjustor to arrange for additional tests or care as needed. Your physician should refer you to another provider within our network, unless the treatment you need is not available within the network.

Second opinionsYou are entitled to one (1) second medical opinion during the course of your recovery. Upon your request, we will choose a network physician—who works within the same specialty as your original physician—to conduct the second opinion consultation. This physician will review your medical history and examine you to confirm the previous physician’s decision or to offer alternatives.

Surgery or hospitalizationWe must preauthorize all surgery or hospital admissions, except in emergency situations. The physician or hospital must call us at 1-800-762-7811 for authorization. If we determine that the procedure or admission is not medically necessary, our medical director may contact your physician for further discussion or to develop an alternative plan of care. We may request second a opinion.

Changing physiciansYou may ask to change your primary physician one (1) time during the course of your claim by calling Summit at 1-800-282-7644. You will need to confirm this request in writing and mail the request to:

Summit Claims CenterPO Box 2928Lakeland, FL 33806-2928

We will select a physician for you within our network and within the physician’s same specialty, within five (5) days of receiving your request. We will choose a provider who is not professionally affiliated with the previous physician. If we fail to provide you with a new physician, you may choose one from the network, within the same specialty. However, you cannot request a change without first seeing the original physician.

You may ask for additional physician changes by contacting us by phone or mail, and your request will be handled through our grievance process. (Please refer to pages 9 through 11 of this guide to learn how to file a grievance.)


Independent medical evaluationsYou may also request one (1) independent medical evaluation (IME) if there is a dispute concerning your medical treatment or disability status. An IME is different from a second opinion. It is a highly extensive and specifically formatted patient case review, used primarily in court. It must be completed by a physician who has never seen you and who is not affiliated with any of your previous physicians. This physician can only render an opinion within his or her own specialty or area of expertise. You are allowed one (1) IME for the life of your claim, and Summit is allowed one (1). We will pay for an IME if the exam is performed by a network physician; otherwise, you will be responsible for the costs. You must contact your adjustor to request an IME.

Document copiesYou have the right to copies of any of your medical reports. (There may be a charge for these documents. Your adjustor can give you more information.)

PrescriptionsWe have a prescription drug program network especially for injured workers through Express Scripts, which allows you to promptly get your prescriptions filled and paid. This program includes many pharmacies and retail chains in your area, such as CVS, Kmart, Publix, Rite Aid, Walgreens and Walmart.

Prescription ID cardWhen you were injured, your employer should have given you a Workers’ Compensation Temporary Prescription ID Card form before you went to the physician. If you receive prescriptions for your injury, you will need to present this form to the pharmacist when you get your first prescription filled. This form allows the pharmacist to give you an initial 7-day supply of medications prescribed for your injury. (A complete list of participating pharmacies is included on the form.) If you did not receive this form, please call your adjustor.

At the time your claim was reported, a prescription card was generated by Express Scripts and mailed to you for prescriptions related to your injury. You should receive this prescription card within one (1) week of your injury being reported. Simply present the card to your participating pharmacist for refills or any new prescriptions after your initial 7-day supply.

For more information about participating pharmacies or for authorization to have a prescription filled without a prescription ID card, please contact your adjustor at 1-800-282-7644 (Monday through Friday, 8:00 a.m. to 5:30 p.m., Eastern Time).

Out of networkAny pharmacy outside of the Heritage Summit network should invoice us directly at the following address:

Summit Claims Center PO Box 2928Lakeland, FL 33806-2928


ReimbursementIf you pay for a prescription yourself, send the receipt to the Summit Claims Center. Your receipt must include the following information:

• Date dispensed • Whether this is a new prescription or a refill • Prescription number • Medication name and strength • National Drug Control number • Quantity dispensed • Number of days supplied • Reason for use of nongeneric drug (when applicable) • Prescribing physician’s name and state license number (from the Florida Department of Health, Division of Medical Quality Assurance) • Charge for each medication billed

Medical billsWe will pay medical providers directly for authorized services. If you receive medical bills, do not pay them. Instead, please call your adjustor or mail them to the following address:

Summit Claims CenterPO Box 2928Lakeland, FL 33806-2928


Your ResponsibilitiesMedical appointmentsYou are responsible for keeping all of your scheduled appointments. If you have problems, call us at 1-800-282-7644.

Drug or alcohol testingIf you are injured on the job and test positive for illegal drugs or alcohol—or if you refuse or fail to take a drug test—you may be denied your workers’ compensation benefits.

At Summit, we want to help our injured workers avoid 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 a charge to you for these tests. If you refuse to take one of these drug tests or fail one, your workers’ compensation benefits may be denied.

Returning to workOur goal is to help you recover from your injuries and return to work as soon as possible. To do that, we help you, your employer and your physician communicate about your recovery. This way, the physician has a clear idea of the job you normally do, and your employer understands your medical condition.

Once you are cleared to return to work, your Summit claims adjustor will work with you, your employer and your physician to create a job that meets your physical limitations, but still allows you to come back to work in some capacity. We call this transitional duty.

Once you have been offered either your normal job or a transitional duty job that is approved by your physician, you are responsible for returning to work. If you refuse to return to work, you may not be eligible for workers’ compensation wage benefits.


Requests, Complaints and Grievance ProceduresOur goal is to provide you with quality medical care, but we know that there may be times when you have questions, concerns or complaints about your medical treatment. If you are dissatisfied with your care, we want to know—and we want to help. Please follow these procedures to notify us about your questions so that we can respond as quickly as possible.

Initial requests for services and changesIf you would like to request a medical service, a second opinion, a change of your authorized physician, or if you have any questions about your medical care, please call us at 1-800-282-7644 (Monday through Friday, 8:00 a.m. to 4:30 p.m., Eastern Time). Ask to speak with your Summit adjustor. If you are still not satisfied, please ask to speak with a supervisor.

When you make your request, we will either answer immediately or ask for more information. If, for some reason, you do not receive a response from us within seven (7) days, or if we deny your request, you can file either a complaint or a grievance.

This initial request related to your medical care is not considered a complaint. A complaint involves you expressing your dissatisfaction to us about your medical care.

ComplaintsA complaint is more serious in nature than an initial request, but less formal than a written grievance. You may make a complaint verbally or in writing. Include a clear explanation of the issue and how you would like to see it resolved. You can mail a written complaint to us at:

Attention: ComplaintsHeritage Summit HealthCare LLCPO Box 2928Lakeland, FL 33806-2928

Once we receive your complaint, we will investigate your situation and attempt to resolve the problem within 10 calendar days. (If everyone involved agrees, we may extend the 10-day deadline.) If your complaint is denied or remains unresolved after 10 days, you may file a written grievance.

You also have the right to contact the Florida Division of Workers’ Compensation Employee Assistance Office in Tallahassee at 1-800-342-1741 for more information about your rights, responsibilities and the dispute resolution process.


GrievancesA grievance is a formal, written way to express your dissatisfaction with the medical care provided or our refusal to provide medical care. It is a serious matter and should not be taken lightly by anyone involved in your claim. You may file a formal grievance only after you have placed an initial request for medical services. We also encourage you to make a complaint prior to filing a written grievance; however, it is not mandatory.

How to file a grievanceTo file a written grievance, you must complete the grievance form (AHCA Form No. 3160-0019 November 2000; a copy is included with this packet of information). No other form or letter can be accepted.

Written grievances must be mailed to the following address:

Attention: Heritage Summit MCA Grievance CoordinatorSummit Claims Center PO Box 2928Lakeland, FL 33806-2928

Your grievance form must include all of the following: • A summary of the issues, including all specifics, such as names, dates and origin of the issue • A clear explanation of how you want the situation resolved • All supporting documentation for each issue

For information on completing the grievance form, you can call us toll-free at 1-800-282-7644 and ask to speak with our grievance coordinator.

The grievance process begins as soon as we receive your form. Your form will not be considered properly filed unless you have first made an initial request.

The standard grievance procedureOnce we receive your properly filed grievance form, we will gather and review your medical information and make an initial decision to grant or deny it within 14 calendar days. If a grievance form is incomplete or improperly filed, it is treated as a complaint.

At your request, we are available to meet and discuss the issues in your grievance. The meeting can be held at a location convenient to you, within our service area.

If your grievance is denied after this first review, it is automatically forwarded to the Heritage Summit formal grievance committee for further consideration (unless you withdraw it in writing). The committee will review your grievance and make a decision within 30 days. The 30-day deadline may be extended if you and the committee agree in writing. If your grievance requires the committee to collect additional information outside of our service area, we will have 14 additional days to make a decision.


Review by the Grievance Committee is considered the final step in the formal grievance process. The grievance process is considered complete when the review by the committee is finished.

If at any point in this process, your grievance is determined to be valid, we will begin the appropriate corrective action within seven (7) days of that decision.

Urgent grievancesIf your grievance is urgent, it will be handled using our expedited procedure, and you should receive an answer within three (3) calendar days.

For your grievance to be classified as urgent, you must provide documentation from an authorized medical provider showing that your medical condition is at significant risk of deterioration within 72 hours if your request is not met.

If your grievance is not deemed urgent by your authorized physician or medical care coordinator at the time of filing, we will follow standard grievance procedures.

Additional grievance informationWe have chosen not to require arbitration as part of the grievance process.

Once the entire grievance procedure has been completed, you have the right to file a Petition for Benefits (Section 440.192, F.S).

Summit will report all formal grievances to the Agency for Health Care Administration (AHCA) no later than March 31 for grievances filed during the previous calendar year.


Explanation of Corporate RelationshipsHeritage Summit HealthCare LLC (Heritage Summit) is the delegated entity for the insurer’s workers’ compensation managed-care arrangement (MCA). The objective of the Heritage Summit MCA is to provide you with prompt and effective medical care, geared toward helping you reach maximum healing and returning to work, if possible.

Heritage Summit is a subsidiary of Summit Consulting LLC (Summit). Summit is the managing general agent for your employer’s workers’ compensation insurance and

helps manage the medical care that you receive for your workers’ compensation injury. Summit is the managing general agent for Bridgefield Casualty Insurance Company, Bridgefield Employers Insurance Company, RetailFirst Insurance Company and BusinessFirst Insurance Company, and is the workers’ compensation service company for The City of Plant City. Summit operates as the parent company for Heritage Summit HealthCare, which has

contracted with the above insurers and the City of Plant City to act as their AHCA-approved delegated entity to provide them with

a managed-care arrangement in Florida.

Heritage Summit provides a managed-care arrangement in Florida. In conjunction with the MCA, Heritage Summit operates a preferred provider organization (PPO) network that includes health-care providers who treat injured workers for workers’ compensation injuries.

Workers’ Compensation Fraud Notice“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 insurance fraud, punishable as provided in s. 817.234.” Fla. Stat. Ann. § 440.105(7) (West 2017). You may not be entitled to Florida workers’ compensation benefits if you commit insurance fraud. Fraudulent workers’ compensation claims are reported to and investigated by the Florida Bureau of Workers’ Compensation Fraud. You can help stop these crimes by reporting any suspected abuses directly to us by calling 1-800-282-7644.

managed care guide · 2018. 11. 9. · the heritage summit managed-care arrangement (mca) is...

Documents