Managed Care

Florida

Summit’s managed-care system is designed to provide you with quality medical care from doctors who specialize in workplace injuries. Managed care simply means that someone, usually a primary care physician, will manage your care. In other words, this person will decide whether you need to return for additional treatment, see a specialist, have therapy, etc.

As part of our managed care plan, we have a network of thousands of doctors and facilities, including hospitals, walk-in clinics and specialists, all dedicated to helping you heal quickly and return to work as soon as possible.

Grievance Procedures

Initial requests
Complaint procedure
What is a grievance?
How to file a grievance
The standard grievance procedure
Urgent grievances
Additional grievance information

We know that there may be times when you have questions, concerns or even complaints about your medical treatment. If you’re dissatisfied with your medical care, we want to know, and we want to help. Please follow these procedures to notify Summit about your question so that we can respond as quickly as possible.

Initial requests

If you would like to request a medical service, a second opinion, a change of your primary care physician, or 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. Ask to speak with your Summit MCA medical services coordinator or case manager. If you are still not satisfied, please ask to speak with a supervisor.

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

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Complaint procedure

An initial request related to your medical care (discussed in the last section) is not considered a complaint. A complaint involves you expressing your dissatisfaction to us about your medical care. It is more serious in nature than an initial request, but less formal than a written grievance. You may make your complaint verbally or in writing. Include a clear explanation of the issue, and how you would like to see it resolved. (For your information, complaints are legally defined in the Florida Statutes (F.S.)—Section 440. 134(1)(b).)

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.

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What is a grievance?

A grievance is a formal way to express your dissatisfaction with your medical care. It is a serious matter, and should not be taken lightly by anyone involved in your claim. (Florida statute defines a grievance in Section 440.134(1)(d), F.S.) You may file a formal grievance only after you have placed an initial request for medical services. Summit reports all formal grievances to the Agency for Healthcare Administration.

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How to file a grievance

  • To file a written grievance, you must complete the grievance form (AHCA Form No. 3160-0019 November 2000). No other form or letter can be accepted.
  • Written grievances must be mailed to the following address:
    • Summit Claims Center
      Attention: Summit MCA Grievance Coordinator
      P.O. Box 2928
      Lakeland, FL 33806-2928
  • Your grievance form must include: (1) a summary of the issues, including all specifics, such as names, dates and origin of the issue; (2) a clear explanation of how you want the situation resolved; and (3) all supporting documentation for each issue.
  • The grievance process begins as soon as we recieve your form.

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The standard grievance procedure

  • Once 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.
  • If your grievance is denied after this first review, it is automatically forwarded to Summit’s 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 the 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 days of that decision.

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Urgent grievances

  • If your grievance is urgent, it will be handled using our expedited procedure, and you should receive an answer within 72 hours.
  • For your grievance to be classified as urgent, you must provide documentation from an authorized medical provider, showing with substantial certainty that death or paralysis will occur within 72 hours if your request is not met.
  • For urgent grievances, all managed-care grievance procedures will be considered complete three days from the time we receive the grievance.
  • If your grievance is not deemed urgent by your primary care physician or medical care coordinator at the time of filing, your grievance will follow the standard procedure.

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Additional grievance information

  • 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 the service area.
  • We may allow, but may not require, arbitration as part of the grievance process. According to state law (Chapter 682, F.S.) an arbitrated grievance is allowed additional time. The grievance process must be completed within 210 calendar days of the date we receive your arbitration request.
  • For more information on the dispute resolution process under Florida law (Chapter 440, F.S.), please contact the Employee Assistance Office of the Division of Workers’ Compensation in Tallahassee at 1-800-342-1741. Once the entire grievance procedure has been completed, you have the right to file a Petition for Benefits (Section 440.192, F.S).

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