Fla. Admin. Code Ann. R. 69L-26.002 - Definitions

For the purposes of these rules, the following definitions shall apply:

(1) "Carrier" means any insurance carrier, or any individually self-insured employer licensed as such pursuant to section 440.38, F.S., or group self-insurance fund licensed as such pursuant to Section 624.462, F.S., providing workers' compensation insurance and including the servicing agent and servicing company of any of the above.

(2) "Contact" as that term is used in Chapter 93-415, Section 24, Laws of Florida. [creating Section 440.191(2)(a), F.S.] means a party to a workers' compensation dispute has made "contact" with the EAO if he or she has done any of the following:

(a) Submitted to the EAO a Request for Assistance form (EAO-1, dated 6/17/94 and hereby incorporated by reference) which meets all the requirements set out in these rules; or

(b) Personally telephoned the EAO, spoken to an EAO representative, requested the assistance of the EAO, and as a result, the EAO has completed a Request for Assistance form (EAO-1) on behalf of the party so requesting.

(c) In the case of a minor or incompetent person, written or oral correspondence in accord with paragraph (2)(a) or (b), above, requesting assistance from the EAO on behalf of the minor or incompetent person by his or her legally appointed guardian, shall constitute "contact" with the EAO for the purposes of these rules.

(d) In the case of a deceased person, written or oral correspondence in accord with paragraph (2)(a) or (b), above, requesting assistance from the EAO on behalf of a deceased person by his or her personal representative shall constitute "contact" with the EAO for the purposes of these rules.

(e) The following will not be accepted by the EAO as a request for assistance and do not constitute "contact" with the EAO for purposes of these rules:

1. Written requests for assistance not submitted in accordance with these rules and on a Request for Assistance form (EAO-1); or

2. Written requests for assistance transmitted to the EAO by fax; or

3. Written requests for assistance not signed by the party to a workers' compensation dispute; or if the party to a dispute has retained an attorney, not signed by that attorney on behalf of the party; or if the party to a dispute is a minor or incompetent person, not signed by his or her legal guardian; or if the party to a dispute is deceased, not signed by his or her personal representative; or if the requestor is a health care provider that has provided authorized treatment to an injured worker, not signed by the health care provider; or

4. Telephone calls of an attorney to the EAO made on behalf of a party to a workers' compensation dispute, unless the attorney is the party to a dispute and is requesting assistance on his or her own behalf.

(3) "Division" means the Division of Workers' Compensation.

(4) "EAO" means the Employee Assistance and Ombudsman Office created by Chapter 93-415, Section 24, Laws of Florida [creating Section 440.191, F.S.]. Information or documentation requested or required by the EAO shall be submitted only to the address and during the regular business hours of the EAO as contained in this rule. The address for the EAO shall be as follows:

(a) For filing of Requests for Assistance: Post Office Box 8010, Tallahassee, Florida 32314-8010.

(b) For responding to requests for information by the EAO: To the address specified by the EAO in the request.

(c) For all other purposes: 200 East Gaines Street, Tallahassee, FL 32399-4224.

The telephone number shall be (850)488-5201 or (800)342-1741. The normal business hours for the EAO shall be 8:00 a.m. to 5:00 p.m., (Eastern Standard Time), Monday through Friday (working days).

(5) "Fax" or "Faxed" means any written communication transmitted by facsimile or telecopy machine.

(6) "Good Faith Effort" means cooperating with the division's efforts to resolve disagreements between the parties. The division shall consider the following factors in determining whether a party or party's attorney has cooperated with the division's efforts:

(a) Whether the party or the party's attorney has telephoned or written to the employer or carrier and communicated that party's complaint or disputed issue(s) to the employer or carrier before requesting assistance from the EAO with that (those) same issue(s).

(b) Whether a party or the party's attorney has provided complete and "specific" (as that term is defined herein) information on a Request for Assistance form (EAO-1), or by telephone, in the event the EAO has completed the form for a party pursuant to a telephoned request for assistance from that party to the EAO.

(c) Whether a party or the party's attorney has timely provided documents in his or her possession or under his or her control to the EAO. The production of documents shall be timely if any documents requested by the EAO which are in the possession or under the control of the party from whom they are requested are submitted to the EAO within five (5) working days of the EAO's request for the documents.

(d) Whether a party or the party's attorney has timely participated in a conference requested by the EAO. Timely means that if feasible and practical, the parties shall: participate in a telephone conference within three (3) working days of a request by the EAO for a telephone conference; or, the parties shall participate in an in-person conference within five (5) working days of a request by the EAO for an in-person conference.

(e) Whether the party or party's attorney has provided true and complete information to the best of his or her ability and knowledge. Every party and attorney participating in the EAO's dispute resolution proceedings shall have an affirmative obligation to correct errors or omissions in information he or she has provided when an error is discovered, and to update all receivers of previously submitted information as soon as it is discovered by the sender that the information previously submitted is no longer accurate or complete.

(7) "Informal Dispute Resolution" means the procedures established by these rules whereby the EAO, in response to a request for assistance in resolving a dispute regarding workers' compensation benefits, conducts an investigation and attempts to facilitate a resolution of any disputed issues.

(8) "JCC" means a Judge of Compensation Claims as that term is defined by Chapter 440, F.S.

(9) "Party" or "Person" includes individuals, children, firms, associations, joint ventures, partnerships, estates, trusts, business trusts, syndicates, fiduciaries, corporations, and all other groups or combinations.

(10) "Requestor" means the person requesting the assistance of the EAO. The requestor may be an actual party to a workers' compensation dispute, or an attorney representing a party to a workers' compensation dispute, or a legal guardian of an incompetent or minor person who is a party to a workers' compensation dispute or the personal representative of a deceased person who is a party to a workers' compensation dispute. The requestor may also be a health care provider that has provided treatment to an injured worker, where the employer or carrier has authorized the treatment by telephone or by fax and subsequently fails or refuses to pay for the treatment authorized.

(11) "Servicing Agent" or "Servicing Company" means any entity which has obtained approval pursuant to Florida law and administrative rule to contract with self-insurers for the purpose of providing all services necessary to plan and maintain an approved self-insurance program.

(12) "Specific" means:

(a) If a disputed issue is indemnity benefits, then in order to make a "specific" request for assistance, the requestor must state on the Request for Assistance form (EAO-1) a classification for each benefit sought, such as: temporary total disability, temporary partial disability, wage loss, permanent total disability, impairment benefit, or supplemental benefits. The requestor must state for each benefit sought and allegedly not paid, the time period for which the injured worker asserts he was eligible to receive the benefits.

(b) If the disputed issue is authorization for a particular health care provider or a particular health care service, then in order to make a "specific" request for assistance, the requestor must state the type of service or name of the health care provider that has been requested, and a justification for any health care services requested and not provided.

(c) If the disputed issue is payment of health care bill(s), then in order to make a "specific" request for assistance, the requestor must state the name and address of the health care provider, the date(s) of service and the amount(s) of the bill(s) for which payment is sought; and, if the requestor is a health care provider, the requestor must provide evidence that the treatment was authorized by the employer or carrier, and that more than 45 days have elapsed since the bill(s) was (were) submitted for payment.

(d) If the disputed issue is mileage or prescription reimbursement, then in order to make a "specific" request for assistance, the requestor must state the drug or product prescribed, the name of the prescribing physician, the dollar amount requested and the date each reimbursement request was submitted to the employer or carrier. Legible copies of each mileage request or prescription, as applicable, must be attached to the Request for Assistance form (EAO-1) or timely provided to the EAO if requested by the EAO.

(13) "Working Day" means a day which is neither a Saturday, Sunday, or legal holiday observed by the State of Florida.

Notes

Fla. Admin. Code Ann. R. 69L-26.002

Rulemaking Authority 440.591 FS. Law Implemented 440.191 FS.

New 9-29-94, Amended 11-25-96, Formerly 38F-26.002, 4L-26.002, Amended 5-12-04.

New 9-29-94, Amended 11-25-96, Formerly 38F-26.002, 4L-26.002, Amended 5-12-04.