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Medicaid: How to Report Adverse Incidents

In the event of a critical incident defined by the Agency for Health Care Administration (AHCA): "Critical events that negatively impact the health, safety, or welfare of enrollees. Critical incidents may include events involving abuse, neglect, exploitation, major illness or injury, involvement with law enforcement, elopement/missing, or major medication incidents."This may result in, but is not limited to, the following:

  • Death
  • Abuse/neglect/exploitation
  • Major medication incident
  • Altercation requiring medical intervention
  • Involvement with law enforcement
  • Member elopement/missing
  • Member major injury
  • Member major illness

Critical Incidents must be reported by both providers and vendors:

  • Provider
    • Any health care professional who administers care to members
    • Excludes Assisted Living Facilities (ALF) and Skilled Nursing Facilities (SNF)
  • Vendor
    • Any subcontracted entity who provides services to members

Providers/vendors with direct patient care must use the WellCare Incident Report form (located on the Provider Resources tab under Adverse Incidents).

Providers/vendors who do not have direct patient care may use their own critical incident report forms.

In the event of an adverse incident as defined by the Agency for Health Care Administration (AHCA) per Code 15 reporting standards, whether occurring in a facility of one of WellCare's providers or arising from care prior to admission to a facility that occurs to a WellCare member.

When adhering to this physician responsibility, it's important to appreciate what the term "adverse incident" means to AHCA and how the Florida Statute for reporting is carried out at WellCare.

There is one critical difference for Health Plans vs. hospital reporting. Hospitals have 15 days to report (hence, the term Code 15). Reporting for health plans is required by Florida Statute, Chapter 59A-12 of the Florida Administrative Code. The initial Code 15 report has to be filed within 24 hours of the occurrence of the event. According to the Adverse Incident Reporting Guide distributed by AHCA, the term "adverse incident" for Code 15 reporting means an event over which health care personnel could exercise control and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred, and results in one of the following injuries:

  • Death
  • Brain or spinal damage
  • The performance of a surgical procedure on the wrong patient
  • The performance of a wrong surgical procedure
  • The performance of a wrong-site surgical procedure
  • The performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient's diagnosis or medical condition
  • The surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process
  • The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure

Adverse/critical incident reports must be completed in their entirety and faxed to: 1-813-283-5475. For any incidents that occur on the weekends (after 5 p.m. Friday), and on holidays, providers must also report the incident immediately to the critical incident email box: 

Please note: The critical incident reports fax is unattended on weekends and holidays. Providers must follow up by emailing the critical incident email for incidents that occur on weekends and holidays.&

The WellCare Board of Directors has final authority for the Risk Management Program and assigns responsibility for operation of the program to the Licensed Healthcare Risk Manager (LHRM). 

It needs to be stressed that the success of the Risk Management Program relies on the internal incident reporting system to identify adverse incidents, so you are an integral part of the program. 

Completed incident reports can be faxed to 1-813-283-5475, Attn: QI Department - Risk Management. 

For additional assistance contact the LHRM at 1-813-206-3792.

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Last Updated On: 4/23/2021
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