Arkansas Administrative Code › Agency 099 - Arkansas Workman's Compensation › Rule 099.00.99-002 - Rule 33 - Managed Care

Current through Register Vol. 49, No. 6, June, 2024
PART I
GENERAL PROVISIONS
Pursuant to Ark. Code Ann. §
								11-9-508
			 (Rpl. 1996), the following rule is hereby established in order to implement a
			 voluntary managed care program.
Rule 33 provides for certification, administration, evaluation
			 and enforcement of managed care organizations (MCO) and internal managed care
			 systems (IMCS).
Pursuant to Ark. Code Ann. §
								11-9-514(a)
			 (3) an Arkansas Managed Care System shall be
			 deemed to exist for a carrier, employer, and/or self-insured employer when more
			 than one approved MCO is available for contracting purposes to cover the
			 insurance carrier/employer, and/or self-insured's employees.
Managed care becomes effective when :
1. the insurance carrier/employer/or
		  self-insured has either contracted with a certified MCO or the insurance
		  carrier/self-insured or employer has obtained certification of its internal
		  managed care system (IMCS, and
2.
		  Notice (Form H) has been posted in accordance with Commission Rule
		  7.
The applicable MCO/IMCS plan will provide all treatment for work
			 related injuries occurring after notice is posted. Previous notice given to
			 employees by a certified MCO shall fulfill the above notice
			 requirements.
A.
DEFINITIONS
For the purpose of this rule, unless the context requires
			 otherwise:
1.
Administrator.
"Administrator" means the Administrator of the
		  Medical Cost Containment Department of the Arkansas Workers' Compensation
		  Commission.
2.
Health Care
		  Providers:
a.
Initial Health Care
		  Provider.
"Initial health care provider" means a physician/provider who
		  is primarily responsible for the treatment of a worker's compensable injury or
		  illness and who is a medical doctor, osteopath, podiatrist, dentist,
		  optometrist, ophthalmologist, chiropractor, or oral surgeon, practicing in and
		  licensed under the laws of Arkansas; or under the laws of another state. This
		  definition shall apply to initial treating physician, regular treating
		  physician, primary care physician, and initial primary care physician as
		  referred to in Ark. Code Ann. §
											11-9-508(d)
		  (5) (A) and §
											11-9-514(a)
		  (3) (A) (ii) -
b.
Nonparticipating Health Care
		  provider.
"Nonparticipating health care provider" means any person,
			 provider, company, professional corporation, organization, or business entity
			 which chooses not to contract with an MCO/IMCS for the delivery of medical
			 services or supplies to injured employees.
c.
Participating Health Care
		  Provider.
"Participating health care provider" means any person,
		  provider, company, professional corporation, organization, or business entity
		  with which the MCO/IMCS has contracts or other arrangements for the delivery of
		  medical services or supplies to injured employees.
d.
Regular Treating Physician.
"Regular treating physician" means the provider/physician who is the regular
		  treating physician of the employee and has maintained the medical records of
		  and has a documented history of treatment with the employee prior to the date
		  of injury.
e.
Optometric or
		  Ophthalmologic Provider.
The injured employee shall have direct access
		  to any optometric or ophthalmologic medical service provider who agrees to
		  provide services under the rules, terms, and conditions regarding services
		  performed by the managed care entity initially chosen by the employer for the
		  treatment and management of eye injuries or conditions. Such optometric or
		  ophthalmologic medical service provider shall be considered a certified
		  provider by the commission. See Ark. Code Ann. §
											11-9-508(e).
3.
Internal Managed Care
		  System.
"Internal managed care system" (IMCS) means a certified in-house
		  managed care system established and operated by an insurance carrier, employer,
		  or self-insured employer.
4.
Managed Care Entity.
"Managed care entity" means a Commission
		  approved MCO or IMCS. See Ark. Code Ann. §
										11-9-508(d)
		  (1) & (5) (A) and §
										11-9-514(a)
		  (3) (A) (i) & (ii) .
5.
Managed Care Organization.
"Managed care organization" (MCO) means an entity certified by the Arkansas
		  Workers' Compensation Commission that provides for the delivery and management
		  of treatment to injured employees and markets these services.
6.
Probation.
"Probation" means
		  that an MCO/IMCS has been given a specified length of time in which to remedy
		  any problem(s) of which it has been notified pursuant to Part
		  II, H of this rule.
7.
Revocation.
"Revocation"
		  means the termination of certification of an MCO/IMCS to provide
		  services.
8.
Specialized
		  Medical Services.
"Specialized medical services" means health care
		  services other than those provided by an initial health care
		  provider.
9.
Suspension.
"Suspension" means that a MCO's authority to enter
		  into new or amended contracts with insurance carriers, employers or
		  self-insured employers has been suspended by the Arkansas Workers' Compensation
		  Commission for a period of time.
B.
INITIAL CHOICE OF PHYSICIAN
The employer shall have the right to select the initial primary
			 care physician from among those associated with managed care entities certified
			 by the Commission. See Ark. Code Ann. §
										11-9-508(d)
			 (5) (A) and §
										11-9-514(a)
			 (3) (A) (i). The Insurance Commissioner may
			 allow a rate reduction for employers who use their carriers' contracted MCO or
			 IMCS exclusively.
C.
REFERRALS
1. Participating
		  Providers
All referrals by participating health care providers or initial
			 healthcare providers shall be to providers who agree to abide by the rules,
			 terms, and conditions of the insurance carrier/employer/self-insured employer's
			 MCO/IMCS.
2.
		  Non-Participating Providers
a.
		  Non-participating providers may provide services under the following
		  circumstances:
(1) Change of physician.
When approving a change of physician, the Commission may
			 authorize a nonparticipating provider/physician to provide services to a worker
			 if:
(a) the provider/physician is the
		  regular treating physician of the employee; and
(b) the provider/physician agrees to refer
		  the employee to the insurance carrier/employer/self-insured employer' s
		  MCO/IMCS for any other treatment that the employee may require; and
(c) the provider/physician agrees to comply
		  with all of the rules, terms, and conditions of the insurance
		  carrier/employer/self-insured employer's MCO/IMCS pursuant to § Ark. Code
		  Ann.
		  11-9-508(d)
		  (5).
(2) Emergency Medical Treatment.
(3) When the employee is referred to such
		  provider/physician by the MCO/IMCS.
D.
CHANGE OF PHYSICIAN
Employees should initially request a change of physician from the
			 insurance carrier/employer/self-insured employer. Within five business days of
			 the employee's initial request for a change of physician, the insurance
			 carrier/employer/self-insured employer shall notify the employee of its
			 decision to grant or deny the change of physician.
Pursuant to Ark. Code Ann. §
										11-9-514(a)
			 (3) where the employer has contracted with a
			 managed care organization certified by the commission, the claimant employee,
			 however, shall be allowed to change physicians by petitioning the Commission
			 one (1) time only for a change of physician, to a physician who must either be
			 associated with the managed care entity chosen by the employer or be the
			 regular treating physician of the employee who maintains the employee's medical
			 records and with whom the employee has a bona fide doctor-patient relationship
			 demonstrated by a history of regular treatment prior to the onset of the
			 compensable injury, but only if the primary care physician agrees to refer the
			 employee to the managed care entity chosen by the employer for any specialized
			 treatment, including physical therapy, and only if such primary care physician
			 agrees to comply with all the rules, terms and conditions regarding services
			 performed by the managed care entity initially chosen by the employer.
Where the employer does not have a contract with a managed care
			 organization, certified by the commission, the claimant employee, however,
			 shall be allowed to change physicians by petitioning the Commission one (1)
			 time only for a change of physician, to a physician who must either be
			 associated with any managed care entity certified by the Commission or be the
			 regular treating physician of the employee who maintains the employee's medical
			 records and with whom the employee has a bona fide doctor-patient relationship
			 demonstrated by a history of regular treatment prior to the onset of the
			 compensable injury, but only if the primary care physician agrees to refer the
			 employee to a physician associated with any managed care entity certified by
			 the Commission for any specialized treatment, including physical therapy, and
			 only if such primary care physician agrees to comply with all the rules, terms,
			 and conditions regarding services performed by any managed care entity
			 certified by the Commission.
Treatment or services furnished or prescribed by any physician
			 other than the ones selected according to the foregoing, except emergency
			 treatment, shall be at the claimant's expense.
E.
MULTIPLE MCOs
When an insurance carrier, employer, or self-insured employer
			 contracts with more than one MCO, the insurance carrier/self-insured employer
			 shall designate to the Commission one MCO whose rules, terms and conditions
			 will apply to services rendered by change of physician and referral
			 providers.
F.
RULES,
		  TERMS, AND CONDITIONS OF MCO/IMCS
Rules, terms, and conditions shall be made available upon request
			 by the Arkansas Workers' Compensation Commission.