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Excerpt: Workers' Compensation System Guide Alex Sink Chief Financial Officer State of Florida Florida Department of Financial Services Workers' Compensation System Guide INTRODUCTION THE WORKERS' COMPENSATION SYSTEM GUIDE IS INTENDED TO GIVE ALL PARTIES A GENERAL OVERVIEW AND SUMMARY OF THE WORKERS' COMPENSATION SYSTEM. IT IS NOT INTENDED TO SUPERCEDE OR TAKE THE PLACE OF THE FLORIDA WORKERS' COMPENSATION LAW (CHAPTER 440, FLORIDA STATUTES) OR FLORIDA WORKERS' COMPENSATION CASE LAW. ITS PURPOSE IS TO ASSIST ALL STAKEHOLDERS IN THEIR ROLES AND RESPONSIBILITIES. IT PROVIDES GENERAL INFORMATION AND REFERENCES THAT MAY ASSIST WITH RESOLVING ISSUES AND ANSWERING QUESTIONS. 2 Date of Issuance: August 2008 Workers' Compensation System Guide GUIDELINES AND RESOURCES CONTENT SECTION TABLE OF CONTENTS Section: Topic Pages I. EMPLOYEE INFORMATION 4-
Workers' Compensation System Guide

Alex Sink Chief Financial Officer State of Florida
Florida Department of Financial Services

Workers' Compensation System Guide

INTRODUCTION

THE WORKERS' COMPENSATION SYSTEM GUIDE IS INTENDED TO GIVE ALL PARTIES A GENERAL OVERVIEW AND SUMMARY OF THE WORKERS' COMPENSATION SYSTEM. IT IS NOT INTENDED TO SUPERCEDE OR TAKE THE PLACE OF THE FLORIDA WORKERS' COMPENSATION LAW (CHAPTER 440, FLORIDA STATUTES) OR FLORIDA WORKERS' COMPENSATION CASE LAW. ITS PURPOSE IS TO ASSIST ALL STAKEHOLDERS IN THEIR ROLES AND RESPONSIBILITIES. IT PROVIDES GENERAL INFORMATION AND REFERENCES THAT MAY ASSIST WITH RESOLVING ISSUES AND ANSWERING QUESTIONS.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES CONTENT SECTION

TABLE OF CONTENTS

Section:

Topic

Pages

I.

EMPLOYEE INFORMATION

4-8

II.

EMPLOYER INFORMATION

9 - 18

III.

HEALTH CARE PROVIDER INFORMATION

19 - 22

IV.

INSURANCE COMPANY INFORMATION

23 - 30

V.

APPENDIX

31 - 37

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYEE SECTION

PART 1
Employee Section

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Workers' Compensation System Guide GUIDELINES AND RESOURCES INJURED WORKER DUTIES: 1. If you have an accident or are injured on the job you must: Tell your employer you have been injured, as soon as possible. The law requires that you report the accident or your knowledge of a job-related injury within 30 days of your knowledge of the accident or injury. When you do so, you must ask your employer what doctor you can see. You must see a doctor authorized by your employer or the insurance company. Your employer may tell you to call the insurance company handling your claim; the name and phone number should be on the "Broken Arm" poster that should be posted at your workplace. If it is an emergency and your employer is not available to tell you where to go for treatment, go to the nearest emergency room and let your employer know as soon as possible what has happened. Your employer is required by law to report your injury to the insurance company within 7 days of when you report your accident or injury. If they do not do this, and they do not give you a phone number for the insurance company to call, you can call the workers' compensation (WC) hotline for assistance at 1-800-342-1741. After you or your employer report the injury to the insurance company, many companies will have an insurance claim adjuster call you within 24 hours to explain your rights and obligations. o If you receive a message and a number to call, you should call as soon as possible to find out what you need to do to get medical treatment. Within 3-5 business days after you or your employer report the accident, you should receive an informational brochure explaining your rights and obligations, and a Notification Letter explaining the services provided by the Employee Assistance Office of the Division of Workers' Compensation. These forms may be part of a packet which may include some or all of the following: o A copy of your accident report or "First Report of Injury or Illness," which you should read to make sure it is correct; o A fraud statement, which you must read, sign and return as soon as possible, or benefits may be temporarily withheld until you do so; o A release of medical records for you to sign and return; and o Medical mileage reimbursement forms that you should fill out, after seeking medical treatment, and send to your claims adjuster for reimbursement. EMPLOYEE SECTION



If you do not receive a call or the information packet from the insurance company, you can call the WC hotline for assistance at 1-800-342-1741.

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2. When you see the doctor: Give the doctor a full description of the accident or how you were injured. Answer all questions the doctor might have about any past or current medical conditions or injuries. Discuss with the doctor if the injury is related to work or not. If related to work, find out if you can work or not. o If you are released to work but can't return to your same job, you should get instructions from the doctor on what work you can and cannot do. o Keep and attend all appointments with your doctor, or benefits may be suspended. 3. After seeing the doctor: Speak with your employer as soon as you leave the doctor. Tell your employer how much your job means to you, and explain to them what work the doctor said you can and cannot do. o If you are admitted to a hospital, call or have someone call your employer for you to explain what happened and where you are. Give your employer the doctor's note as soon as possible. Ask your employer if they have work for you to return to that does not require you to do things the doctor said you cannot do yet. o If yes, ask when you should report for work. o If not, make sure your employer has a way to contact you if appropriate work becomes available. Contact the insurance company and let them know what the doctor said about your injuries and work status. You should continue to stay in contact with your employer and the insurance company throughout your treatment and recovery. 4. Benefits you may receive: Money you may be entitled to: o Indemnity Benefits: If you are unable to work for more than 7 days, you should receive money to partly replace what you were not able to earn after your accident. Temporary total disability: If your doctor says you cannot work at all: You should receive money equaling about 66 2/3% of your regular wages at the time you were hurt. Your benefit is paid to you beginning with the 8th day you lose time from work. The first 7 days lost from work is only paid if you lose more than 21 days from work. If your injury is critical, you may receive 80% of your regular wages for up to 6 months after the accident.

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EMPLOYEE SECTION

You can receive up to a total of 104 weeks of temporary total disability and/or temporary partial disability benefits

Temporary partial disability: If you can return to work, but you cannot earn the same wages you earned at the time you were hurt: You will receive money equaling 80% of the difference between 80% of what you earned before your injury and what you are able to earn after your injury. Example: Your average weekly wage: $320 (Earnings before injury) X .80 = $256 Your weekly earning after injury: -$150 $106 $106 X .80 = $84.80 Weekly temporary partial disability benefit: $84.80


You can receive up to a total of 104 weeks of temporary total disability and/or temporary partial disability.

Impairment benefits: Once your doctor says you are at Maximum Medical Improvement, you are as good as he or she expects you to get. At this point your doctor should evaluate you for: Possible permanent work restrictions and, A permanent impairment rating. If you receive a permanent impairment rating, you will receive money based on that rating. Medical treatment: Your employer is responsible for providing medical treatment. o Do not delay in getting a doctor's appointment from your employer or insurance company. o Do not go on your own to your private doctor for treatment. The insurance company must authorize the doctor who is to treat you. If you do not get a doctor's name from the insurance company, you should contact your adjuster and ask for a doctor. Vocational rehabilitation assistance you may receive: If you are unable to return to your job because of permanent work restrictions resulting from your on-the-job injury, you may obtain assistance from the Workers' Compensation Vocational Rehabilitation Section of the Florida Department of Education at the following web site or phone numbers: o http://www.rehabworks.org/ o Telephone: (850) 245-3470



For assistance on how any of the above benefits are calculated, call the WC hotline at 1-800-342-1741. 7
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5. If you have a dispute with your insurance company: First, try to talk about the problem with your adjuster or their supervisor. If you still need assistance, contact the WC hotline at 1-800-342-1741. If the insurance company still will not agree to pay the benefits that you believe you are entitled to, you can file a Petition for Benefits with the Office of the Judges of Compensation Claims. o You may wish to hire an attorney to represent you in this action. o See Appendix B, a flow chart of the dispute process. For assistance on how to fill out and file a Petition for Benefits, call the WC hotline at 1-800342-1741. 6. Employee Workers' Compensation Criminal Violations: The following are criminal violations of s. 440.105, F.S., that constitute a felony of the first, second or third degree depending on the monetary value of the fraud as provided in s. 775.082, s. 775.083, or s. 775.084, F.S.: Filing a false claim of on-the-job injuries or exaggerating injuries. o An injured employee or any party making a claim of an on-the-job injury will be required to provide his or her personal signature attesting that he or she has reviewed, understands, and acknowledges the following statement: "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." o If the injured employee or party refuses to sign the document, benefits or payments shall be suspended until such signature is obtained. HOW TO GET MORE INFORMATION AND HELP WITH YOUR CLAIM: 1. Division of Workers' Compensation Employee Assistance and Ombudsman Office: The Employee Assistance and Ombudsman Office (EAO) will assist you at no cost with questions or concerns you may have about your workers' compensation claim. EAO works on your behalf to resolve issues with your workers' compensation claim. EAO offices are located around the state to assist you. o Website: http://www.myfloridacfo.com/wc/organization/eao.html o Phone (toll free): 1-800-342-1741 2. The Division of Workers' Compensation Website: www.myfloridacfo.com/WC For additional information click on "Information and FAQs" on the left side of the Division's homepage. NOTE: See appendix for additional website information.

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PART 2
Employer Section

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYER DUTIES: 1. If you see an accident on the job or someone reports one: Contact your insurance company right away. Stay in contact with your employee and the adjuster until the injured worker is back on the job. 2. If the employee is released to work with restrictions: Get the doctor's list of restrictions from the injured worker or directly from the doctor's office, and Meet with the injured worker to see if work is available that he/she can do. If restricted work is available: o Discuss with the injured worker: Starting time and date, What you can pay him/her based on new job duties, and o Report the restricted work to the adjuster. Inform the adjuster: o When the injured worker is scheduled to return to restricted work. o If the injured worker will not be earning what he/she earned before: Send the adjuster wage information on a weekly or bi-weekly basis to determine if temporary partial benefits are due. o If the injured worker is unable to, due to restrictions, continue working, or o If you can't give him/her restricted work any longer, or o If the doctor releases him/her to regular work. For assistance, call the WC hotline at 1-800-342-1741. EMPLOYER SECTION

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EMPLOYER REQUIREMENTS: 1. Posting Requirement: The "Broken Arm Poster" and the "Anti-Fraud Notice" should be posted in a conspicuous place and should identify the name of the insurance company providing coverage and where to call to report an accident or injury. Contact your insurance company to obtain the poster and the notice. 2. Recording Requirement: Record all workplace injuries and retain the records for at least 2.5 years. 3. Reporting Requirement: Report all workplace deaths to the Division within 24 hours of discovery. o Call 1-800-219-8953 or 850-922-8953 Report all job-related injuries to the insurance company within 7 days of discovery. Provide a copy of the injury report to the injured worker (Form DFS-F2-DWC-1). Report required wage information to the insurance company within 14 days of learning of an injury that will require the employee to miss work for more than 7 days or that results in a permanent impairment. If requesting the employee's authorization for release of social security benefit information, give the Form DFS-F2-DWC-14 to the employee, submit the Request for Social Security Disability Benefit Information to the Social Security Administration office nearest to the employee's address, and send a copy of the completed form to the Division within 14 days of the request (Form DFS-F2-DWC14). PENALTIES THAT CAN BE ASSESSED AGAINST EMPLOYERS: If the First Report of Injury (DFS-F2-DWC-1) is filed late with the Division, due to the late reporting of the accident by the employer to the insurance company, the employer may be penalized according to the following schedule: $100 for 1 through 7 days of untimely filing. $200 for 8 through 14 days of untimely filing. $300 for 15 through 21 days of untimely filing. $400 for 22 through 28 days of untimely filing. $500 for over 28 days of untimely filing.

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WORKERS' COMPENSATION COVERAGE/COMPLIANCE REQUIREMENTS FOR THE EMPLOYER: Chapter 440, F.S., establishes workers' compensation coverage requirements for employers. 1. Construction Industry: An employer in the construction industry who employs one or more part- or full-time employees must obtain workers' compensation coverage. Sole proprietors, partners, and corporate officers are considered employees. In the construction industry only, members of a limited liability company are considered corporate officers. Corporate officers may elect to exempt themselves from the coverage requirements of Chapter 440. A construction industry contractor, who sub-contracts all or part of their work, must obtain proof of workers' compensation coverage or a Certificate of Election to be Exempt from all sub-contractors, prior to work being done. If the sub-contractor is not covered or exempt, for purposes of workers' compensation coverage, the sub-contractor's employees shall become the employees of the contractor. The contractor will be responsible to pay any worker's compensation benefits to the sub-contractor and its employees. 2. Non-Construction Industry: An employer in the non-construction industry, who employs four or more part- or full-time employees, must obtain workers' compensation coverage. Corporate officers are considered employees, unless they elect to exempt themselves from the coverage requirements of Chapter 440. Sole proprietors and partners in the nonconstruction industry are not considered to be employees unless they elect to be employees. 3. Agricultural Industry: Agricultural employers with five or more regular employees and/or 12 or more seasonal employees, who work for more than 30 days, must obtain workers' compensation liability coverage for those employees. 4. Out-of-State Employers: Any construction industry employer having one or more part- or full-time employees performing work in Florida is required to obtain a Florida policy through a Florida-licensed insurance company. The company must use the Florida job classification codes, approved manual insurance premium rates, rules, and manuals prior to beginning work in Florida. If the construction industry employer has an out-of-state policy, the insurance company must be licensed in Florida, and Florida must be listed in Section 3A of the policy.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYER SECTION

OBTAINING REQUIRED COVERAGE: 1. Coverage Options: Contact a Florida-licensed insurance agent to obtain a workers' compensation policy. If the employer is unable to obtain coverage through the private insurance market, they may contact the Florida Workers' Compensation Joint Underwriting Association (FWCJUA) at (941) 378-7400 or go to their website at www.fwcjua.com. The employer may also consider leasing employees from a Professional Employer Organization or PEO. In this circumstance, the PEO becomes the employer and provides workers' compensation coverage to each employee who is paid by the leasing PEO. 2. Accurate Employer Job Classification and Payroll: Since workers' compensation premiums are based on the information provided by the employer, it is important that accurate information such as what type of work is being performed (i.e. interior trim carpentry, roofing, restaurant, clerical, etc.) and estimated payroll for each job classification code is reported to the insurance company. If any changes occur in the job duties or services performed or the employer's payroll amount during the policy term, the employer must notify its insurance company. 3. Professional Employer Organization or Employee Leasing Company: If an employer enters into an employee leasing agreement with a licensed employee leasing company, the agreement entails workers' compensation coverage only for employees listed with the employee leasing company. The client company is responsible for workers' compensation coverage for all non-leased employees. The payroll for all leased employees must be paid through the leasing company. Any changes in job duties or status of an employee must be reported to the leasing company promptly. 4. Individual Self Insurers: Pursuant to chapter 440.38, F.S., an employer may become individually self insured and secure the payment of workers' compensation by providing proof of financial strength necessary to ensure timely payments of current and future claims. Authorization and regulation of individual self insurers is through the Division. 5. Commercial Self-Insurance Funds: Pursuant to chapter 624.462, F.S., a group of persons may form a commercial self-insurance fund for purposes of pooling and spreading liabilities for any commercial and/or casualty insurance. Authorization and regulation of commercial self-insurance funds is through the Office of Insurance Regulation

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYER SECTION

WORKERS' COMPENSATION EXEMPTION ELIGIBILITY REQUIREMENTS AND INFORMATION: 1. General Information: An individual who meets the eligibility requirements to obtain an exemption pursuant to s. 440.05, F.S., may elect an exemption from the coverage requirements of Chapter 440, F.S. Once an exemption is obtained, the exempted individual may not receive workers' compensation benefits when he/she sustains a work-related injury. o Certificates of Election to be Exempt shall apply only to the corporate officer named on the Notice of Election to be Exempt and apply only within the scope of the business or trade listed on the Notice of Election to be Exempt. o Exemptions are effective on the date they are issued by the Division. 2. Construction Industry Exemption Requirements: The corporation must be registered and listed as active with the Florida Department of State, Division of Corporations. The applicant must be listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations. Members of a limited liability are considered corporate officers (in the construction industry only). The applicant must own at least 10 percent of the stock of the corporation as evidenced by a stock certificate or, in the case of an LLC, a statement attesting to the minimum 10 percent ownership. A $50.00 application fee is required. No more than three officers of a corporation (including LLC) or of any group of affiliated corporations (including LLCs) may elect to be exempt.





**Construction exemptions are valid for a period of 2 years or until a revocation is filed or until revoked by the Division. The original effective and expiration dates are listed on the Certificate of Election to be Exempt, which is mailed to the exempted individual. The exemption information, including effective and expiration dates, can also be found on the Division's "Proof of Coverage" database, at: www.myfloridacfo.com.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES 3. Non-construction Industry Exemption Requirements: The corporation must be registered and listed as active with the Florida Department of State, Division of Corporations. The applicant must be listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations. There is no limit to the number of corporate officers eligible to obtain an exemption. There is no application fee. EMPLOYER SECTION

**Non-construction exemptions are valid until a voluntary revocation is filed or the exemption is revoked by the Division. **Non-construction limited liability insurance company members are not eligible to elect to be exempt from the coverage requirements of Chapter 440, F.S. 4. How to Obtain an Exemption Application: The Notice of Election to be Exempt (Form DWC-250) can be obtained from the Division's website at http://www.myfloridacfo.com/WC/. Once on the site, click on "Rules and Forms" on the left side of the page. On that page, click on the third green Tab "69L-6" from the left. From that page you can download all exemption-related forms, including the DWC-250 and the corresponding instructions. For additional information about workers' compensation exemptions, please call customer service at 850-413-1601. You may also contact the Division of Workers' Compensation, Bureau of Compliance at 800-742-2214. If you do not have access to the Internet you may request a copy of the application via telephone.



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DIVISION OF WORKERS' COMPENSATION ENFORCEMENT AUTHORITY 1. Enforcement and Authority: The Florida Division of Workers' Compensation is responsible for enforcing employer compliance with the coverage requirements of the workers' compensation law. Compliance investigators have the authority to enter and inspect any place of business for purposes of ensuring employer compliance with workers' compensation law. Investigators can also request an employer's business records. An employer must produce the required business records within five business days of receiving the Division's written request for records. The failure of an employer to comply with the workers' compensation coverage requirements is considered to pose an immediate danger to public health, safety, and welfare; the Division shall issue a stop-work order within 72 hours of determination of non-compliance, stopping all business operations. If an employer conducts business operations in violation of a stop-work order, the employer shall be assessed an additional penalty of $1,000 per day for each day of violation.



2. A Stop-Work Order Can Be Issued: When an employer who is required to secure Florida workers' compensation coverage fails to do so; When the employer fails to provide records requested by the Division of Workers' Compensation within five business days of request; When an employer understates or conceals payroll, misrepresents or conceals employee duties or fails to utilize Florida's class codes and workers' compensation rates.

3. A Stop Order May Be Released: When an employer provides proof of compliance and pays the assessed monetary penalty, or pays the required down payment and enters into a payment agreement with the Division. The penalty is a minimum of $1,000 and is based on the insurance premiums which should have been paid, but were not (evaded premium), multiplied by 1.5 for the prior three years.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYER SECTION

EMPLOYER WORKERS' COMPENSATION CRIMINAL VIOLATIONS: The following are criminal violations of s. 440.105, F.S., and constitute a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083, F.S. It is unlawful to knowingly: o Coerce or attempt to coerce, as a precondition to employment or otherwise, an employee to obtain a certificate of election of exemption pursuant to s. 440.05, F.S. o Discharge or refuse to hire an employee or job applicant because the employee or applicant has filed a claim for benefits. o Discharge, discipline, or take any other adverse personnel action against any employee for disclosing information to the division or any law enforcement agency relating to any violation or suspected violation of any of the provisions of Chapter 440. o Fail to update applications for coverage as required by s. 440.381(1), F.S., within 7 days after the reporting date for any change in the required information, or to post notice of coverage pursuant to s. 440.40, F.S. o Participate in the creation of the employment relationship in which the employee has used any false, fraudulent, or misleading oral or written statement as evidence of identity. The following are criminal violations of 440.105, F.S., and constitute a felony of the first, second or third degree depending on the monetary value of the fraud as provided in s. 775.082, s. 775.083, or s. 775.084, F.S.: Working without workers' compensation coverage, if required. Submitting an altered or fraudulent certificate as proof of coverage for workers' compensation insurance or a false "exemption" certificate. Misclassifying employees to lower premiums or treating employees as subcontractors when they are not in order to hide or conceal payroll. Violating a stop-work order. Employees and Employers can submit a fraud referral to Division of Insurance Fraud on line at https://secure.myfloridacfo.com/fraud/NonIndustryRSF.asp or by calling toll-free 1-800-3780445 (inside Florida) or 850-413-3261 (outside Florida). A reward of up to $25,000 may be offered to citizens for information leading to an arrest and conviction in complex fraud schemes.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES EMPLOYER SECTION

COMPLIANCE AND COVERAGE ASSISTANCE MAY BE OBTAINED FROM: 1. Construction Policy Tracking Database: The Construction Policy Tracking Database provides information to contractors regarding the coverage status of the contactors they use. This easy-to-use system will send contractors automatic electronic notification of any changes to their sub-contractors' coverage status. The only action required of the contractor is to register and list the sub-contractors for whom he/she would like to receive coverage notification. 2. Proof of Coverage Database (Compliance): The Compliance Database provides information regarding workers' compensation coverage and exemptions from workers' compensation for employers. 3. Noncompliance Referral Form (Whistle Blower): This form must be completed to report an employer you suspect has failed to secure required workers' compensation insurance coverage. 4. Compliance Stop-Work Order Database: The Compliance Stop-Work Order Database lists employers that have been issued a stop-work order. 5. Notice of Election to be Exempt (Form DWC-250): The form can be obtained from the Division's website at http://www.myfloridacfo.com/wc/. Once on the site, click on "Rules and Forms" on the left side of the page. On that page, click on the third green Tab "69L6" from the left. From that page you can download all exemption-related forms, including the DWC-250 and the corresponding instructions. These and other databases can be found at http://www.myfloridacfo.com/WC/.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES HEALTH CARE PROVIDER SECTION

PART 3
Health Care Provider Section

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Workers' Compensation System Guide GUIDELINES AND RESOURCES HEALTH CARE PROVIDER SECTION

HEALTH CARE PROVIDER DUTIES: 1. A certified health care provider must be familiar and comply with the workers' compensation statutes, rules and reimbursement manuals. Section 440.13, F.S., addresses the statutory guidelines for providing medical treatment and care under the workers' compensation health care delivery system. Ch. 69L-7, Florida Administrative Code (F.A.C.), addresses the health care provider's responsibilities for successfully participating and providing medical treatment under the workers' compensation system. A physician or recognized practitioner, as defined in 440.13(1)(h), F.S., who wishes to be a certified health care provider must submit a certification application (Form 3160-0020) to the Division of Workers' Compensation, Office of Medical Services. The application can be found on-line at www.MyFloridaCFO.com/wc. Providers in an agreement with a licensed workers' compensation managed care arrangement and health care facilities licensed under s. 395, F.S., s. 400, F.S., and s. 429, F.S., are exempt from the certification application process. Certification is required for a health care provider to receive payment from an insurance company for medical care provided to an injured worker, except in emergencies, as defined in s. 395.002, F.S. Only a health care provider certified by the Division of Workers' Compensation can be authorized by an insurance company to render medical services and treatment under Florida's Workers' Compensation Program. Chapter 69L-7: Workers' Compensation Medical Reimbursement and Utilization Review specifically addresses the certified health care provider responsibility for: Providing only care authorized by the insurance company and medically necessary to treat the compensable medical condition; Providing medical documentation, records and reports to support the medical necessity of the treatment rendered and to communicate to the insurance company, the medical condition of the injured employee; Identifying work limitations and restrictions to facilitate return to work; Properly completing and filing DFS-F5-DWC-25 forms within three business days of the initial treatment and, thereafter, within 24 hours of each subsequent or follow-up visit, upon occurrence of an actionable event or change in the injured employees' medical condition or the treatment plan, or at a maximum once every 30 days. Cooperating with efforts by the insurance company and the Division to resolve disputes arising from medical treatment and care rendered; Completing and filing medical claim bills consistent with established billing and reporting policies.

2.

3.

4.



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Workers' Compensation System Guide GUIDELINES AND RESOURCES HEALTH CARE PROVIDER SECTION

5.

A certified health care provider must get authorization from the self-insured employer or insurance company before providing medical care to an injured worker, or payment may be denied. The DFS-F5-DWC-25 form is the required document that certified health care providers must use to request authorization for treatment. The request for authorization must be submitted to the insurance company if the employer is not self-insured. Prior authorization is not required when emergency treatment and care, as defined in s.395.002, F. S., is needed to treat the injured employees medical condition(s). When an injured worker is being given emergency treatment, the provider may verify the name of the employer and/or insurance company in the Division's Proof of Coverage Database. The self-insured employer or insurance company must respond to authorization requests for treatment by the end of the third business day after receiving a request, or within 10 days for bills exceeding $1,000. A self-insured employer or insurance company's failure to respond to a written request for authorization within 3 or 10 business days, as required by statute, will constitute authorization. Payment for authorized treatments must be made within 45 days. The billing and medical treatment report forms that must be used are identified in section 69L-7.602, F.A.C. (See appendix for forms and links).





6. Only physicians licensed by the Florida Department of Health under chapters 458, 459, 460, 461, 463, or 466, F.S., can determine permanent impairment. The impairment rating guide to be used for calculation of impairment rating is specific to the date of accident as follows: AMA, 3rd EDITION for date of injury on or prior to 6/30/90. MINNESOTA GUIDE for date of injury on 07/01/90 through 06/20/93 1993 Florida Impairment Rating Guide (FIRG) for date of injury on 06/21/93 through 01/07/97. 1996 FL Uniform P.I.R. Schedule for date of injury on 01/08/97 and thereafter.

For further information, please refer to Florida law, s. 440.15(3)(b).

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7. The Florida Workers' Compensation Health Care Provider Reimbursement Manual, contains the Maximum Reimbursement Allowances determined by the Three-Member Panel, pursuant to Section 440.13(12), F.S. The Three-Member Panel establishes reimbursement policies, guidelines, codes and maximum reimbursement allowances for services and supplies provided by health care providers. The manual also includes payment policies for pharmacists and medical suppliers. Ambulatory surgical centers should use the Florida Workers' Compensation Reimbursement Manual for Ambulatory Surgical Centers. Hospitals should follow the Florida Workers' Compensation Reimbursement Manual for Hospitals. 8. Non-payment complaints are filed with the Division's Employee Assistance Office at 1-800342-1741. Reimbursement dispute petitions are filed with the Office of Medical Services, 200 East Gaines Street, Tallahassee, Florida 32399-4232.

HEALTH CARE PROVIDER CRIMINAL VIOLATIONS: The following are criminal violations of 440.105, F.S., and constitute a felony of the first, second or third degree depending on the monetary value of the fraud as provided in s. 775.082, s. 775.083, or s. 775.084, F.S.: Any physician licensed under chapter 458, 459, 460, 461, 463, or 466 or any other practitioner licensed under the laws of this state who knowingly and willfully assists, conspires with, or urges any person to fraudulently violate any of the provisions of this chapter. Any person or governmental entity licensed under chapter 395 to maintain or operate a hospital in such a manner as to knowingly and willfully allow the use of the facility in a scheme or conspiracy to fraudulently violate any of the provisions of Chapter 440.

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Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

PART 4
Insurance Company Section

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

INSURANCE COMPANY DUTIES: 1. The Insurance Company has the responsibility to: Adjust claims without harassment, coercion, or intimidation. Investigate any knowledge or notice of a claim to assure prompt delivery of disability and medical benefits to an injured worker and ensure an efficient and self-executing system. o This knowledge includes, but is not limited to, receipt of any information, written or verbal, from any source reporting an accident or injury or requesting authorization to treat an injury. Electronically file policy information with the Division. File a First Report of Injury or Illness and mail copies to the injured worker and the employer. Respond to requests for medical treatment by authorized doctors within 3 business days after receipt of a written request. Send to the injured worker, within 3 days of knowledge of the injury, a brochure explaining the injured worker's rights and benefits under the law and the Employee Notification Letter. Obtain a signed fraud statement from the injured worker. Pay the first installment of compensation for total disability or death benefits within 14 days after the employer receives notification of the injury or death. o This applies where the injured worker can't return to work and begins losing time from work immediately following the accident and continues to lose time past 7 days. o If the injured worker loses days from work that are not continuous, then the first installment of compensation is due on the 6th day after the first 8 calendar days of disability. Investigate and, if denying the claim, do so within 14 days of obtaining knowledge of the accident or injury. If more than 14 days are needed to investigate the claim: o Send the 120-day letter to the injured worker; o Timely initiate benefits; and o If denied, file a denial of the claim within 120 days of the initial provision of benefits. Pay, disallow, or deny all medical, dental, pharmacy and hospital bills properly submitted to the insurance company within 45 days after receipt of a completed bill on the proper form. Obtain the DWC-25 form to document the work status and treatment plan of the injured worker. Authorize or deny medical referrals in writing, from authorized health care provider, within 3 business days of receipt of the request. o If the referral for testing, examination or treatment is more then $1,000, the authorization or denial must be made within 10 business days of receipt of the written request.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES Reporting responsibilities of the claims handler:
Form 1. Information for Employees or Employers Mail an informational brochure to the injured worker within 3 business days after notification of the injury or illness. Annually mail an informational brochure to the employer. Provide a paper copy of the injury report to the worker and employer within three days when notified of an injury by phone or electronic data interchange (EDI) Provide a paper copy of the form DFS-F2-DWC-4 to the employer and employee for actions or changes specified in rule. Provide a paper copy of the form DFS-F2-DWC-12 to the employer and employee for any denial or rescission of benefits. For dates of accident on or after 10/1/03 involving temporary disability, provide an informational letter to eligible injured workers explaining the benefits and requirements of temporary partial disability within five days of learning of the worker's release to restricted work. 2.* Forms Reported to the Division of Workers' Compensation Proof of coverage (POC): Submit to the Division by electronic data interchange policy information for Certificates of Insurance, Endorsements, Reinstatements, Cancellations and Non-Renewals pursuant to the filing time periods in Rule 69L-56.210, F.A.C. DFS-F2-DWC-60 or DFS-F2-DWC-61 DFS-F2-DWC-65 or DFS-F2-DWC-66 DFS-F2-DWC-1 or Form IA-1 DFS-F2-DWC-4 DFS-F2-DWC-12 N/A Rule 69L-3.0035 69L-3.0036 69L-3.0045

INSURANCE COMPANY SECTION

69L-3.0091 69L-3.012 69L-3.0191 69L-3.01915

69L-3.0045 Complete and submit a copy of the First Report of Injury or Illness (paper) 69L(DFS-F2-DWC-1) to the Division for lost-time and death cases 56.301 (EDI) within 14 days of learning of the injury or as otherwise required by rule. For electronic reporting in compliance with 69L-56.300, submit a FROI (First Report of Injury) or a FROI and SROI (Subsequent Report of Injury) as provided in the rule. Report to the Division on a DFS-F2-DWC-4 certain significant DFS-F2-DWC-4 69L-3.0091 changes in a lost-time case (as specified in the rule) within 14 days (paper) (paper) 69Lof making or learning of the change. For electronic reporting in FROI, SROI (EDI) 56.304 69Lcompliance with 69L-56.300, submit a FROI or a SROI as provided 56.3045 (EDI) in the rule. DFS-F2-DWC-12 69L-3.012 Upon denial of benefits or rescission of a prior denial, report such (paper) 69Laction to the Division on a DFS-F2-DWC-12 as provided in the rule. (paper) FROI, SROI (EDI) 56.3012 (EDI) For electronic reporting in compliance with 69L-56.300, submit a FROI or a SROI as provided in the rule. *Requirements for filing hardcopy forms of the DWC-1, 4, 12, 13 and 49 apply ONLY to those insurance companies still transitioning to electronic filing (EDI) of those forms.

(IAIABC standards for POC, Release 2.1, 10/01/06 Edition and Supplement); DFSF5-DWC-EDI-1; DFS-F5-DWC-EDI2; DFS-F5-DWCEDI-3 DFS-F2-DWC-1 (paper) FROI, SROI (EDI)

69L-56.100

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

* Forms Reported to the Division of Workers' Compensation Form Rule (continued) Make periodic reports of cumulative benefits paid in lost-time cases DFS-F2-DWC-13 69L-3.016 on a DFS-F2-DWC-13 at intervals specified in the rule. For (paper) (paper) 69Lelectronic reporting in compliance with 69L-56.300, submit a SROI SROI (EDI) 56.3013 (EDI) as provided in the rule. DFS-F5-DWC-9 69L-7.602 Submit all medical, dental, pharmacy, and hospital claims for both medical only and lost-time cases to the Division within 45-calendar DFS-F5-DWC-10 DFS-F5-DWC-11 days of when the medical bill is paid, adjusted, disallowed or DFS-F5-DWC-90 denied. File all forms electronically in the format specified in the Florida Medical EDI Implementation Guide (2007). 69L-3.0194 69LWithin 14 days after request by the Division, file a completed Form DFS-F2-DWC-35 3.01945 DFS-F2-DWC-35 (Permanent Total Supplemental Worksheet) with the Division's Permanent Total Section. DFS-F2-DWC-33 69L-3.0194 69LWithin 14 days after a request by the Division, file a completed 3.01945 Form DFS-F2-DWC-33 (Permanent Total Offset Worksheet) with the Division's Permanent Total Section. 69L-3.0213 DFS-F2-DWC-49 Report any cases changing claims handler to the Division either on (paper) 69Lform DFS-F2-DWC-4 for each individual case or as an aggregate on (paper) form DFS-F2-DWC-49 within 30 days after the effective date of the FROI, SROI (EDI) 56.304 (EDI) change. For electronic reporting in compliance with 69L-56.300, submit a FROI or a FROI and SROI as provided in the rule. DFS-F2-DWC-14 69L-3.021 If requesting the employee's authorization for release of social security benefit information, furnish the Form DFS-F2-DWC-14 to the employee, submit the Request for Social Security Disability Benefit Information to the Social Security Administration office nearest to the employee's address, and send a copy of the completed form to the Division within 14 days of the request. *Requirements for filing hardcopy forms of the DWC-1, 4, 12, 13 and 49 apply ONLY to those insurance companies still transitioning to electronic filing (EDI) of those forms.
Other forms for reporting information to the Division may be required for dates of injury prior to October 1, 2003. Please contact the Division for further information.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

SPECIAL DISABILITY TRUST FUND: The Special Disability Trust Fund (SDTF) was created by the Florida Legislature in 1955 and operates under the authority granted by Chapter 440.49, Florida Statutes. The SDTF was created to encourage the re-employment of injured workers by mitigating the potential liability to the employer from a second injury to the employee. The SDTF reimburses insurance companies and eligible self-insured employers (referred to as the employer/carrier) for expenses incurred due to claims from an employee that meets the eligibility requirements of the statute and case law. Section 440.49(7), Florida Statutes, limits reimbursement to injuries occurring prior to January 1, 1998. Thus, the SDTF has been prospectively abolished; although, the SDTF continues to receive, review, accept, and reimburse eligible claims and levy assessments against companies and self-insurers. ASSESSMENTS: Insurance companies, assessable mutuals, self-insurance funds and individual self-insurers are required to pay the Division assessments to support the Workers' Compensation Administration Trust Fund and the Special Disability Trust Fund. The assessment is applied on a calendar year basis and is based upon actual and calculated premiums. The Workers' Compensation Administration Trust Fund assessment rate was reduced to 0.25% for calendar year 2008 and will remain the same for 2009. The Special Disability Trust Fund assessment has remained constant at 4.52%.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

PENALTIES THAT CAN BE ASSESSED AGAINST INSURANCE COMPANIES: 1. Medical CPS Timely Disposition Penalties: The Division shall impose penalties for late payments or disallowances or denials of medical, hospital, pharmacy, or dental bills that are below a minimum 95% timely performance standard. The insurance company shall pay to the Workers' Compensation Administration Trust Fund a penalty of: Twenty-five dollars for each bill below the 95% timely performance standard, but meeting a 90% timely standard. Fifty dollars for each bill below a 90% timely performance standard.

2. Medical CPS Timely Filing Penalties: Insurance companies that fail to submit a minimum of 95% of all medical reports timely are subject to an administrative fine. Each untimely filed medical report which falls below the 95% requirement is subject to the following penalty schedule: 1-30 calendar days late $5; 31-60 calendar days late $10; 61-90 calendar days late $25; 91 or greater calendar days late $100. 3. Medical CPS Rejected Not Resubmitted Penalties: Each medical report that does not pass the electronic reporting edits shall be rejected by the Division and considered not filed. If the medical report remains rejected and not corrected, resubmitted and accepted by the Division for greater than 90 days, an administrative fine shall be assessed in the amount of $100 for each such medical report. 4. CPS Penalty Calculation for Each Untimely Filing of the First Report of Injury (DWC-1): $100 for 1 through 7 days of untimely filing. $200 for 8 through 14 days of untimely filing. $300 for 15 through 21 days of untimely filing. $400 for 22 through 28 days of untimely filing. $500 for over 28 days of untimely filing.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES 5. INSURANCE COMPANY SECTION

Audit Penalties: S. 440.20(8), F.S., states the Division shall assess a $50 penalty for each payment of indemnity that is below the minimum 95% performance standard and equal to or greater than a 90% timely payment performance standard. The Division shall assess a penalty of $100 for each payment of compensation below the 90% timely payment performance standard. S. 440.525, F.S., states that willful or non-willful administrative penalties may be assessed for unreasonable delay in claims handling, timeliness and accuracy of payments and reports under 440.13, 440.16 and 440.185, F.S. or patterns or practices of harassment, coercion, or intimidation of claimants.

PENALTIES AND INTEREST FOR LATE PAYMENT OF COMPENSATION PAID DIRECTLY TO THE INJURED WORKER ALONG WITH THE INDEMNITY PAYMENT THAT WAS LATE: 1. If any installment of compensation for death or dependency benefits, or compensation for disability benefits payable without an award is not paid within 7 days after it becomes due, there shall be added to such unpaid installment a penalty of an amount equal to 20 percent of the unpaid installment, which shall be paid at the same time as, and in addition to, such installment of compensation. 2. If any installment of compensation is not paid when it becomes due, the employer, insurance company or servicing agent shall pay interest at the rate of 12 percent per year from the date the installment becomes due until it is paid, whether such installment is payable without an order or under the terms of an order. The interest payment shall be the greater of the amount of interest due or $5.

INSURANCE COMPANIES UNLAWFUL ACTION: It shall be unlawful for any insurance entity to revoke or cancel a workers' compensation insurance policy or membership because an employer has returned an employee to work or hired an employee who has filed a workers' compensation claim.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES INSURANCE COMPANY SECTION

INSURANCE COMPANIES ANTI-FRAUD RESPONSIBILITIES: Rule Chapter 69D-2, F.A.C. was adopted September 15, 2006, requiring insurance companies and health maintenance organizations (HMO) to file updated Special Investigations Unit (SIU Descriptions or anti-fraud plans pursuant to section 626.9891, F.S. The type of filing required depends on the insurance company's volume of Florida annual direct written premium. Those insurance companies that write $10 million or more in annual direct written premium are subject to s. 626.9891(1), F.S. and 69D-2.003, F.A.C. and those that write less than $10 million in annual direct written premium are subject to s. 626.9891(2), F.S. and 69D-2.004, F.A.C. For instructions on required anti-fraud filings, click on "Instructions for Filing SIU Descriptions and Anti-fraud plans to IFPR" found on the Division of Fraud website http://myfloridacfo.com/fraud/. Filings are required to be submitted via Division of Insurance Fraud's on-line electronic database known as IFPR (Insurance Fraud Plan Reporting). Use form DFS-L1-1689/SIU for more than $10 million in Florida annual direct written premium. Use form DFS-L1-1690/Anti-fraud plans if less than $10 million in Florida direct written premium. Insurance companies are required to report suspect fraud and can submit a fraud referral to Division of Insurance Fraud on-line at https://secure.myfloridacfo.com/fraud/IndustryRSF.asp.

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Date of Issuance: August 2008

Workers' Compensation System Guide GUIDELINES AND RESOURCES APPENDIX SECTION

PART 5
APPENDIX

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Date of Issuance: August 2008

Workers' Compensation System Guide

APPENDIX A

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Date of Issuance: August 2008

Workers' Compensation System Guide

APPENDIX B

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Date of Issuance: August 2008

Workers' Compensation System Guide

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Date of Issuance: August 2008

Workers' Compensation System Guide ADDITIONAL RESOURCES WC website: www.myfloridacfo.com EMPLOYEE SECTION The State of Florida Employee Assistance Office: http://www.myfloridacfo.com/wc/organization/eao_offices.html Email: wceao@myfloridacfo.com WC Claims Database: https://apps.myfloridacfo.com/claimsweb/ClaimSearch.aspx WC Insurance Company/Claims Handler Database: http://www.myfloridacfo.com/WCAPPS/Carrier/Car_Srch10.asp WC Rehabilitation and Reemployment Program: http://www.rehabworks.org/index.cfm?fuseaction=SubMain.WorkersComp EMPLOYER SECTION Anti-Fraud Reward Program Notice Poster (see #18): http://www.myfloridacfo.com/wc/publications.html Broken Arm Poster (see #16): http://www.myfloridacfo.com/wc/publications.html Bureau of Compliance District Offices: http://www.myfloridacfo.com/wc/organization/boc_offices.html Construction Policy Tracking Database: http://www.myfloridacfo.com/WCAPPS/Contractor/logon.asp Compliance Stop-Work Order Database: http://www.myfloridacfo.com/WCAPPS/SWO/SWOquery.asp Proof of Coverage Database (Compliance): http://www.myfloridacfo.com/WCAPPS/Compliance_POC/wPages/query.asp Noncompliance Referral Form (Whistle Blower): http://www.myfloridacfo.com/WCAPPS/Whistle_Blow/Whistle_Blow.asp WC Forms: http://www.myfloridacfo.com/WC/forms.html WC hotline:1-800-342-1741

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Date of Issuance: August 2008

Workers' Compensation System Guide ADDITIONAL RESOURCES WC website: www.myfloridacfo.com WC hotline:1-800-342-1741

WC Compliance Proof of Coverage Query database: http://www.myfloridacfo.com/WCAPPS/Compliance_POC/wPages/query.asp

HEALTH CARE PROVIDER SECTION Dental Claim Form, DFS-F5-DWC-11: http://ada.org/ A copy of the DWC-11 can be obtained by contacting the American Dental Association http://ada.org/. Instructions for using the DWC-11 http://www.myfloridacfo.com/wc/pdf/DWC-11instr_1-1-07.pdf Disputed Reimbursement Rule, Ch. 69L-31: https://www.flrules.org/gateway/ChapterHome.asp?Chapter=69L-31 Petition for Resolution of Reimbursement Dispute: http://www.myfloridacfo.com/wc/pdf/DFS-3160-0023.pdf Florida WC Uniform Medical Treatment/Status Reporting Form, DFS-F5-DWC-25: http://www.myfloridacfo.com/wc/pdf/DFS-F5-DWC-25.doc Instructions for using: http://www.myfloridacfo.com/wc/pdf/DFS-F5-DWC-25instr.pdfExcel interactive instructions: http://www.myfloridacfo.com/wc/pdf/DFS-F5-DWC-25.xls

Health Care Provider Application for Certification: http://www.myfloridacfo.com/wc/pdf/DFS-3160-0020.pdf Health Care Provider Tutorial: http://www.myfloridacfo.com/wc/HCP_tutorial_2006.pps Expert Medical Advisor Certification Application: http://www.myfloridacfo.com/wc/pdf/DFS-3160-0021.pdf

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Date of Issuance: August 2008

Workers' Compensation System Guide ADDITIONAL RESOURCES WC website: www.myfloridacfo.com WC hotline:1-800-342-1741

Health Insurance Claim Form, DFS-F5-DWC- 9 (CMS 1500): Sample form: http://www.cms.hhs.gov/cmsforms/downloads/CMS1500805.pdf To purchase this form for use, contact a local form vendor or call 1-800-482-9367 X.1770 for vendor information. Instructions for certified health care providers: http://www.myfloridacfo.com/wc/pdf/DWC-9instrHCP_1-1-07.pdf Instructions for ambulatory surgical centers: http://www.myfloridacfo.com/wc/pdf/DWC-9instrASC_1-1-07.pdf Instructions for Pain Management Programs: http://www.myfloridacfo.com/wc/pdf/DWC-9instrWHPM_1-1-07.pdf Hospital Billing Form (UB-04) (CM1450), DFS-F5-DWC-90 (see page 18): Sample form: http://www.cms.hhs.gov/Transmittals/downloads/R1104CP.pdf To purchase this form for use, contact a local form vendor or call 1-800-482-9367 X.1770 for vendor information. Instructions for using the DWC-90: http://www.myfloridacfo.com/wc/pdf/UB-04_B_Completion_Instructions.pdf WC Compliance Proof of Coverage Query database: http://www.myfloridacfo.com/WCAPPS/Compliance_POC/wPages/query.asp

Statement of Charges for Drugs and Medical Supplies Form, DFS-F5-DWC-10, Form: http://www.myfloridacfo.com/wc/pdf/DFS-F2-DWC-10.pdf Reimbursement Manual for Ambulatory Surgical Centers Menu, 2006 Edition, (ASC Reimbursement Manual): http://www.myfloridacfo.com/WCAPPS/CPT/CPT_Agree6.asp The Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2007 Edition: http://www.myfloridacfo.com/WCAPPS/CPT/CPT_Agree8.asp Florida Workers' Compensation Reimbursement Manual for Hospitals, 2006 Edition: http://www.myfloridacfo.com/WC/pdf/2006HOSP.pdf Petition for Resolution of Reimbursement Dispute: http://www.myfloridacfo.com/wc/pdf/DFS-3160-0023.pdf

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Date of Issuance: August 2008

Workers' Compensation System Guide ADDITIONAL RESOURCES WC website: www.myfloridacfo.com WC hotline:1-800-342-1741

Laws regarding Florida's Workers' Compensation, Chapter 440, F.S.: http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch 0440/titl0440.htm Rules regarding Florida's Workers' Compensation: http://www.myfloridacfo.com/wc/forms.html

INSURANCE COMPANY SECTION Electronic Data Interchange (Edi) Requirements for Proof of Coverage and Claims (NonMedical) Rule: http://www.myfloridacfo.com/wc/pdf/69L-56Effective1-7-07.pdf WC Publications and Reimbursement Manuals: http://www.myfloridacfo.com/wc/publications.html Form DFS-L1-1689/SIU Description: Form DFS-L1-1689 (Word) Form DFS-L1-1689 (PDF) Form DFS-L1-1690/Anti-fraud plans: Form DFS-L1-1690 (Word) Form DFS-L1-1690 (PDF)

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Date of Issuance: August 2008

File Size: 496.5 kB
Pages: 38
Date: October 28, 2008
File Format: PDF
State: Florida
Category: Workers Compensation
Word Count: 8,766 Words, 56,529 Characters
Page Size: Letter (8 1/2" x 11")
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