Florida workers’ compensation law requires medical providers to obtain prior authorization for all non-emergency treatment.
Below are key authorization requirements and resources to help Florida providers know when to request prior authorization.
General Rule: Authorization Before Treatment
Florida workers’ compensation requires providers to obtain authorization before delivering any non-emergency services.
- Required: All non-emergency services must receive prior authorization from the claims administrator.
- Do not provide non-emergency treatment until the claims administrator approves the authorization request.
- Track the response deadline: The claims administrator must respond within 3 business days by phone or in writing.
All non-emergency treatment is automatically authorized if the claims administrator does not respond within 3 business days.
Emergency Care
Florida workers’ comp allows providers to render emergency care immediately, but strict notification rules apply.
When administering emergency care, providers must adhere to the following notification deadlines:
- Notify the claims administrator by the close of the 3rd business day after providing emergency care.
- If the emergency results in hospital admission, notify the claims administrator by phone within 24 hours after the initial treatment.
Important: Emergency care is compensable only if the injury arose from a work-related accident.
Referrals
When treating injured workers in Florida, providers must obtain prior authorization for all referrals to other providers or facilities, with limited exceptions.
- Prior authorization required: All referrals to other providers or facilities
- Exception: Referrals made during emergency care do not require prior authorization.
Specialty Services ($1,000+)
Services costing $1,000 or more are not reimbursable unless one of the following applies:
- The claims administrator expressly authorizes the services, or
- The claims administrator fails to respond ot the authorization request within 10 days, or
- The services are provided as emergency care.
Treatment Plan Authorization
In Florida workers’ comp, authorization of a treatment plan does not guarantee approval of individual services.
- Unless otherwise stated, individual services must be specifically authorized by the claims administrator.
Florida |
Statute/Rule |
Statute |
|
Section |
440.13 Medical Services and Supplies; Penalty for Violations; Limitations |
Subsection Text |
440.13 (3) (a) As a condition to eligibility for payment under this chapter, a health care provider who renders services must receive authorization from the carrier before providing treatment. This paragraph does not apply to emergency care.
440.13 (3) (b) A health care provider who renders emergency care must notify the carrier by the close of the third business day after it has rendered such care. If the emergency care results in admission of the employee to a health care facility, the health care provider must notify the carrier by telephone within 24 hours after initial treatment. Emergency care is not compensable under this chapter unless the injury requiring emergency care arose as a result of a work-related accident. Pursuant to chapter 395, all licensed physicians and health care providers in this state shall be required to make their services available for emergency treatment of any employee eligible for workers’ compensation benefits. To refuse to make such treatment available is cause for revocation of a license.
440.13 (3) (c) A health care provider may not refer the employee to another health care provider, diagnostic facility, therapy center, or other facility without prior authorization from the carrier, except when emergency care is rendered. Any referral must be to a health care provider, unless the referral is for emergency treatment, and must be made in accordance with practice parameters and protocols of treatment as provided for in this chapter.
440.13 (3) (d) A carrier must respond, by telephone or in writing, to a request for authorization from an authorized health care provider by the close of the third business day after receipt of the request. A carrier who fails to respond to a written request for authorization for referral for medical treatment by the close of the third business day after receipt of the request consents to the medical necessity for such treatment. All such requests must be made to the carrier. Notice to the carrier does not include notice to the employer.
440.13 (3) (i) Notwithstanding paragraph (d), a claim for specialist consultations, surgical operations, physiotherapeutic or occupational therapy procedures, X-ray examinations, or special diagnostic laboratory tests that cost more than $1,000 and other specialty services that the department identifies by rule is not valid and reimbursable unless the services have been expressly authorized by the carrier, unless the carrier has failed to respond within 10 days to a written request for authorization, or unless emergency care is required. The insurer shall authorize such consultation or procedure unless the health care provider or facility is not authorized, unless such treatment is not in accordance with practice parameters and protocols of treatment established in this chapter, or unless a judge of compensation claims has determined that the consultation or procedure is not medically necessary, not in accordance with the practice parameters and protocols of treatment established in this chapter, or otherwise not compensable under this chapter. Authorization of a treatment plan does not constitute express authorization for purposes of this section, except to the extent the carrier provides otherwise in its authorization procedures. This paragraph does not limit the carrier’s obligation to identify and disallow overutilization or billing errors. |
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