Source: https://www.revisor.mn.gov/rules/5218/full
Timestamp: 2019-06-25 15:11:10
Document Index: 313272369

Matched Legal Cases: ['arts 5218', 'art 5218', 'art 4', 'arts 5218', 'arts 5218', 'arts 5218', 'arts 5218', 'art 5218', 'art 2', 'art 5218', 'art 1', 'arts 3', 'art 5218', 'art 1', 'art 5218', 'art 5218', 'art 1', 'art 5218', 'art 5218', 'art 5218', 'art 5218', 'art 2', 'art 5218', 'art 1', 'art 5218', 'arts 5218', 'art 5218', 'art 1', 'arts 5218', 'art 5218', 'art 6', 'art 5218', 'art 1', 'art 1', 'art 1', 'art 5218', 'art 5218', 'art 2', 'art 5218', 'art 5221', 'art 2', 'art 5221', 'art 3', 'art 5221', 'arts 5218', 'arts 5218', 'arts 5218', 'arts 5218']

CHAPTER 5218, MANAGED CARE FOR INJURED WORKERS
5218.0010 DEFINITIONS.
5218.0020 AUTHORITY.
5218.0030 PURPOSE AND SCOPE.
5218.0040 PROVISIONAL CERTIFICATION.
5218.0200 COVERAGE RESPONSIBILITY OF MANAGED CARE PLAN.
5218.0300 REPORTING REQUIREMENTS FOR CERTIFIED MANAGED CARE PLAN.
5218.0400 COMMENCEMENT AND TERMINATION OF CONTRACT WITH PARTICIPATING PROVIDERS.
5218.0600 CHARGES AND FEES.
5218.0700 DISPUTE RESOLUTION.
5218.0750 UTILIZATION REVIEW AND PEER REVIEW.
5218.0760 MEDICAL CASE MANAGEMENT.
5218.0800 MONITORING RECORDS.
5218.0900 SUSPENSION; REVOCATION.
The terms used in parts 5218.0010 to 5218.0900 have the meanings given them in this part.
"Commissioner" means the commissioner of the Department of Labor and Industry or a designee.
"Emergency care" means those medical services that are required for the immediate diagnosis and treatment of medical conditions that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.
"Employee" means an employee entitled to treatment of a personal injury under Minnesota Statutes, section 176.135.
"Health care provider" has the meaning given in Minnesota Statutes, section 176.011, subdivision 24.
"Insurer" means the insurer providing workers' compensation insurance required by Minnesota Statutes, chapter 176, and includes a self-insured employer except as otherwise provided in part 5218.0200, subpart 4.
"Managed care plan" means a plan certified by the commissioner that provides for the delivery and management of treatment to injured employees under Minnesota Statutes, sections 176.135 and 176.1351.
Participating health care provider.
"Participating health care provider" means any person, provider, company, professional corporation, organization, or business entity with which the managed care plan has contracts or other arrangements for the delivery of medical services or supplies to injured employees.
"Payer" refers to any entity responsible for payment and administration of a workers' compensation claim under Minnesota Statutes, chapter 176.
Primary treating health care provider.
"Primary treating health care provider" means a physician, chiropractor, osteopathic physician, podiatrist, or dentist directing and coordinating the course of medical care to the employee.
"Revocation" means the termination of a managed care plan's certification to provide services under parts 5218.0010 to 5218.0900.
"Suspension" means the managed care plan's authority to enter into new or amended contracts with insurers has been suspended by the commissioner for a specified period of time.
18 SR 1379; L 2016 c 119 s 7
Parts 5218.0010 to 5218.0900 are adopted under the commissioner's rulemaking authority under Minnesota Statutes, section 176.1351, subdivision 6.
18 SR 1379
The purpose of parts 5218.0010 to 5218.0900 is to establish procedures and requirements for certification as a managed care plan relating to the management and delivery of medical services to injured employees within the workers' compensation system under Minnesota Statutes, sections 176.135, subdivision 1, paragraph (f), and 176.1351. No person or entity shall hold itself out to be a workers' compensation managed care entity unless the entity is a certified managed care plan under this chapter.
A managed care plan provisionally certified under the emergency rules may continue to operate with the provisional certification under parts 5218.0010 to 5218.0900, provided that the managed care plan must submit a new application by January 28, 1994. To maintain certification, a certified managed care plan must submit an annual report required by part 5218.0300, subpart 2.
A managed care plan shall provide comprehensive medical services according to its certification and Minnesota Statutes, chapter 176, and all other applicable statutes and rules.
Contracts and coverage.
A managed care plan must contract with the insurer liable for coverage of employees with a personal injury under Minnesota Statutes, chapter 176. Contracts with the insurer must include the provisions required by part 5218.0300, subpart 1, and are subject to the conditions of coverage in subparts 3 to 6.
Insurers may contract with multiple managed care plans to provide coverage for employers. When an insurer contracts with multiple managed care plans to cover the same employer, each employee shall have the initial choice within a reasonable time designated by the employer and insurer to select the managed care plan that will manage the employee's care. The employee must select a managed care plan from those that have a contract with the insurer liable for the personal injury under Minnesota Statutes, chapter 176, and that provide services within the mileage restrictions under part 5218.0100, subpart 1, item F, subitem (7).
Restrictions on employer or insurer formed plans.
Any person or entity, other than a workers' compensation insurer licensed under Minnesota Statutes, chapter 79A, or an employer for its own employees, may apply for certification as a certified managed care plan. A self-insured employer, an entity licensed under Minnesota Statutes, chapter 62C or 62D, or a preferred provider organization that is subject to Minnesota Statutes, chapter 72A, is eligible for certification. An employee of a certified managed care plan shall not be required to obtain services under the plan.
This subpart does not restrict cooperative efforts, whether by contract or otherwise, between a managed care plan, employer, third party administrator, and insurer to accomplish the purposes of Minnesota Statutes, section 176.1351.
An employee who gives notice to an employer of a compensable personal injury under Minnesota Statutes, chapter 176, on or after the effective date of the managed care plan contract with the insurer liable for the injury under Minnesota Statutes, chapter 176, shall receive medical services in the manner prescribed by the terms and conditions of the managed care plan contract. An employee may not be required to receive medical services under the managed care plan until the notice required by part 5218.0250 is given to the employee.
If the employer received notice of the injury before the effective date of the managed care plan contract, the employee may continue to treat with a nonparticipating provider who has been treating the injury until the employee requests a change of doctor. At that time, further services shall be provided by the managed care plan according to part 5218.0100, subpart 1, item F, subitems (2) and (3). Services by health care providers who are not participating providers must be delivered according to part 5218.0500.
Except as provided in part 5218.0500, an employer may elect to require an employee who has notified the employer of a claimed workers' compensation injury to receive treatment from a certified managed care plan before the employer accepts or denies liability for the injury. In such cases, the employer is liable for the cost of any treatment related to the claimed personal injury that is given by a participating health care provider before notice is given to the employee of a denial of liability, even if the employer is later determined to be not liable for the claimed injury. If liability is denied, the employer cannot pursue reimbursement from the employee. This item does not limit the employer's right to pursue any other applicable subrogation or reimbursement rights it may have against another entity.
The employee may receive treatment from any health care provider chosen by the employee after a notice of denial of liability has been given to the employee, or if the employer, after notice of a claimed injury, does not require the employee to receive treatment from a managed care plan prior to accepting liability for a claimed injury. If the employer later accepts liability or is determined by the commissioner, a compensation judge, or an appellate court to be liable for the claimed injury, the employer is responsible for the cost of all reasonable and necessary medical treatment received by the employee from the health care provider. If the employer admits liability for the claimed injury within 14 days after receiving notice of the injury, the employer may require that further medical treatment be received through the managed care plan unless the employee had a documented history of treatment with the health care provider as described in part 5218.0500, before the injury. If liability is admitted or determined later than 14 days after notice of the injury and the employee has been receiving treatment from a nonparticipating provider under this item, the employee is not required to receive further treatment under the managed care plan, if the health care provider agrees to comply with part 5218.0500, subpart 2.
To ensure continuity of care, the managed care plan contract shall specify the manner in which an injured employee with a compensable injury will receive medical services when a managed care plan contract or a contract with a health care provider terminates. When a contract with a health care provider terminates, or when managed care plan coverage for an injured employee is being transferred from one managed care plan to another, the employee may continue to treat with the health care provider under the terminated contract until the employee requests a change of doctor. At that time further services shall be provided under the managed care plan in accordance with the procedures in part 5218.0100, subpart 1, item D, subitem (3), units (b) and (c). Services by providers who are not participating providers must be performed according to part 5218.0500.
18 SR 1379; L 2106 c 119 s 7
Contracts; modifications.
A managed care plan shall provide the commissioner with a copy of the following contracts.
Contracts between the managed care plan and any insurer or self-insured employer, signed by the parties, within 30 days of execution of the contracts. Standard contracts may be submitted instead of individual contracts if no modifications are made. Standard contracts must include a list of signatories and a listing of all employers covered by each contract including the employer's names, unemployment benefits identification number, and estimated number of employees governed by the managed care plan contract. Amendments and addendums to the contracts must be submitted to the commissioner within 30 days of execution. Contract provisions must be consistent with parts 5218.0010 to 5218.0900 and Minnesota Statutes, section 176.1351. The contract must specify the billing and payment procedures and how the medical case management and return to work functions will be coordinated.
New types of agreements between participating health care providers and the managed care plan that are not identical to the agreements previously submitted to the department under part 5218.0100, subpart 1, item E, subitem (1), which shall not be effective until approved by the commissioner.
Contracts between the managed care plan and any entity, other than individual participating providers, that performs some of the functions of the managed care plan.
In order to maintain certification, each managed care plan shall provide on the first working day following each anniversary of certification the following information in items A to D. The annual report must be accompanied by a nonrefundable fee of $400:
a current listing of participating health care providers, including provider names, types of license, specialty, business address, telephone number, and a statement that all licenses are current and in good standing;
a summary of any sanctions or punitive actions taken by the managed care plan against its participating providers;
a report that summarizes peer review, utilization review, reported complaints and dispute resolution proceedings showing cases reviewed, issued involved, and any action taken; and
a report of educational opportunities offered to participating providers and a summary of attendance.
Any of the proposed changes to the certified managed care plan in items A to C, other than changes to the health care provider list, must be reported and may not be implemented under the plan until approved by the commissioner. Submitted changes must be accompanied by a nonrefundable fee of $150:
amendments to any contract with participating health care providers;
amendments to contracts between the managed care plan and another entity performing functions of the managed care plan; and
any other amendments to the managed care plan as certified.
Insurers; data.
The managed care plan must report to the insurer any data regarding medical services and supplies related to the workers' compensation claim required by the insurer to determine compensability in accordance with Minnesota Statutes, sections 176.135, subdivision 7, and 176.138, and any other data required by rule.
The commissioner shall require additional information from the managed care plan if the information is relevant to determining the managed care plan's compliance with parts 5218.0100 to 5218.0900 and Minnesota Statutes, section 176.1351.
18 SR 1379; L 1997 c 66 s 80; L 1999 c 107 s 66; L 2000 c 343 s 4
Prospective new participating health care providers under a managed care plan shall submit an application to the managed care plan. A director, executive director, or administrator may approve the application under the requirements of the managed care plan. The managed care plan shall verify that each new participating health care provider meets all licensing, registration, and certification requirements necessary to practice in Minnesota or other applicable state of practice.
A participating provider may elect to terminate participation in the managed care plan or be subject to cancellation by the managed care plan under the requirements of the managed care plan. Upon termination of a provider contract, the managed care plan shall make alternate arrangements to provide continuing medical services for an affected injured employee under the plan in accordance with part 5218.0200, subpart 6.
A health care provider who is not a participating health care provider may provide medical services to an employee covered by a managed care plan in any of the circumstances in items A to D. The employer or insurer must notify the managed care plan of treatment under items A, B, and D and the managed care plan, employer, or insurer must initiate the contact with the nonparticipating provider. The managed care plan must explain its requirements and procedures to the nonparticipating health care provider, and must provide the plan's toll-free telephone number through which the nonparticipating provider may obtain information about the plan's requirements and procedures and other information specified in part 5218.0100, subpart 1, item L.
To deliver services to an employee under subpart 1, items A and D, a health care provider who is not a participating health care provider must:
Any dispute under subpart 1 or 2 relating to the employee's selection of a health care provider who is not a managed care plan participating health care provider shall be resolved according to part 5218.0700. Any dispute relating to a health care provider's compliance with the managed care plan standards and procedures or treatment standards adopted by the commissioner shall be resolved according to part 5218.0700. A health care provider who has been informed that an injured employee is covered by a managed care plan and who does not comply with the requirements in subpart 2 is subject to denial of payment for the services in accordance with the procedures in part 5218.0700 and sanctions under Minnesota Statutes, section 176.103.
Billings for medical services under a managed care plan shall be submitted in the form and format as prescribed in part 5221.0700, subpart 2. The payment by the insurer or the managed care plan to participating and nonparticipating health care providers for medical services shall be according to the time frames and procedures in part 5221.0600, subpart 3, and Minnesota Statutes, section 176.135, subdivision 6, and shall be the amount allowed under part 5221.0500 and Minnesota Statutes, section 176.136, subdivisions 1a and 1b. A managed care plan may not require a health care provider to accept a lesser payment or pay a fee as a condition of receiving referrals from or becoming a participating provider in the plan.
Disputes that arise on an issue related to managed care shall first be processed without charge to the employee or health care provider through the dispute resolution process of the managed care plan. The managed care plan dispute resolution process must be completed within 30 days of receipt of a written request. If the dispute cannot be resolved, the parties may proceed under Minnesota Statutes, sections 176.106 and 176.305.
18 SR 1379; L 2014 c 182 s 8
The managed care plan must implement a system for peer review to improve patient care and cost-effectiveness of treatment. Peer review must include at least one health care provider of the same discipline being reviewed. The peer review must be designed to evaluate the quality of care given by a health care provider to a patient or patients. The plan must describe in its application for certification how the providers will be selected for review, the nature of the review, and how the results will be used.
The managed care organization must implement a program for utilization review. The program must include the collection, review, and analysis of group data to improve overall quality of care and efficient use of resources. In its application for certification, the managed care plan must specify the data that will be collected, how the data will be analyzed, and how the results will be applied to improve patient care and increase cost-effectiveness of treatment.
Role of case manager.
The medical case manager must monitor, evaluate, and coordinate the delivery of quality, cost-effective medical treatment, and other health services needed by an injured employee, and must promote an appropriate, prompt return to work. Medical case managers must facilitate communication between the employee, employer, insurer, health care provider, managed care plan, and any assigned qualified rehabilitation consultant to achieve these goals. The managed care plan must describe in its application for certification how injured employees will be selected for case management, the services to be provided, and who will provide the services.
Qualifications of medical case manager.
Case management for an employee covered by a managed care plan must be provided by a licensed or registered health care professional. Case managers must have at least one year's experience in workers' compensation.
The commissioner shall monitor and conduct periodic audits and special examinations of the managed care plan as necessary to ensure compliance with the managed care plan certification and performance requirements.
All records of the managed care plan and its participating health care providers relevant to determining compliance with parts 5218.0010 to 5218.0900 and Minnesota Statutes, section 176.1351, shall be disclosed within a reasonable time after request by the commissioner. Records must be legible and cannot be kept in a coded or semicoded manner unless a legend is provided for the codes.
The release of records filed with the commissioner is subject to Minnesota Statutes, sections 13.37, 145.61 to 145.67, 176.231, subdivisions 8 and 9, 176.234, and 176.138. If a managed care plan believes that portions of its application are nonpublic trade secret data under Minnesota Statutes, section 13.37, subdivisions 2 and 3, the plan's application must clearly identify the portions of the application it identifies as trade secret in a separate appendix or appendices.
The plan must also submit with the application an analysis of how each section of the appendix it has characterized as trade secret satisfies each of the three parts of the statutory definition of trade secret under Minnesota Statutes, section 13.37, subdivision 2. Absent a clear indication to the contrary, a written opinion submitted by an attorney identifying and analyzing portions of the application as meeting the statutory requirements for a trade secret under Minnesota Statutes, section 13.37, subdivision 2, shall be considered prima facie showing of a trade secret.
Complaints; investigation.
Complaints pertaining to violations of parts 5218.0010 to 5218.0900 or Minnesota Statutes, section 176.1351, by the managed care plan shall be directed in writing to the commissioner. On receipt of a written complaint, or after monitoring the managed care plan operations, the department shall investigate the alleged violation. The investigation may include, but shall not be limited to, request for and review of pertinent managed care plan records. If the investigation reveals reasonable cause to believe that there has been a violation warranting suspension or revocation of certification, the commissioner shall initiate a contested case proceeding under Minnesota Statutes, chapter 14.
Under Minnesota Statutes, section 176.1351, subdivision 5, the certification of a managed care plan issued by the commissioner shall be suspended or revoked by the commissioner if:
service under the plan is not being provided according to the terms of the certified plan;
the plan for providing services or the contract with the insurer or health care provider fails to meet the requirements of parts 5218.0010 to 5218.0900 or Minnesota Statutes, section 176.1351;
the managed care plan fails to comply with parts 5218.0010 to 5218.0900 and Minnesota Statutes, section 176.1351, or requirements of utilization and treatment standards adopted under Minnesota Statutes, section 176.83;
any false or misleading information is submitted by the managed care plan or participating provider;
the managed care plan continues to use the services of a health care provider whose license, registration, or certification has been suspended or revoked, or under Minnesota Statutes, section 176.103, or who is ineligible to provide treatment to an injured employee under Minnesota Statutes, section 256B.0644; or
the managed care plan is formed, owned, or operated by an insurer.
No employee is covered by a contract between a managed care plan and insurer if the managed care plan's certification is revoked. The managed care plan may reapply for certification as specified in the order of revocation. Upon suspension of certification, the managed care plan may continue to provide services under contracts in effect if the commissioner determines injured employees will continue to receive necessary medical services under Minnesota Statutes, section 176.135.