Arkansas Administrative Code › Agency 099 - Arkansas Workman's Compensation › Rule 099.00.97-003 - WCC Form H - Health Notice for Managed Care

Current through Register Vol. 49, No. 6, June, 2024
Arkansas Workers' Compensation Commission (AWCC) Rule
			 33
requires your Employer to post this Form H
in accordance with Commission Rule
			 7.
Employee Managed Care Notice
Your employer has contracted with the following Managed Care
			 Organization (MCO):
Name
______________________________________________________________________________
Address
____________________________________________________________________________
or has been certified as an Internal Managed Care Systems
			 (
IMCS
).
You are required to receive treatment
			 through this MCO/IMCS if you receive a work related injury, if you do not
			 receive treatment through this MCO/IMCS, or you do not obtain permission to not
			 use this MCO/IMCS, then you may he required to pay for the treatment you
			 receive.
Emergency treatment is exempt from this
			 requirement.
Employees are covered under the MCO/IMCS
after
posting of Form H. Previous notice given to employees by a certified MCO shall
			 fulfill the above notice requirements.
The telephone number of your employer's MCO/IMCS
			 is_______________________________. You may call this number if you have
			 questions about managed care or if you need names of physicians.
if you are injured an the job, you should notify your supervisor
			 immediately. Your supervisor will arrange for treatment or explain what you
			 need to do to receive treatment for your injury.
If you have a problem with your
MCO/IMCS
or dispute
			 about this
MCO/IMCS
, you may file a complaint. A complaint should
			 be filed within thirty (30) days of the occurrence. To obtain information
			 contact your supervisor, the
MCO/IMCS
, or the Medical Cost
			 Containment Department at the AWCC ( 1-800-622 -4472).
If you are balance billed for a covered workers' compensation
			 injury by a physician, you should notify your employer. Balance billing occurs
			 when the physician has been paid according to the MCO/IMCS contract or the
			 Arkansas Workers' Compensation Fee Schedule, and the amount they were paid is
			 less than the amount of their bill and they attempt to collect the difference
			 from the employee.
Choice/Change of Physician is controlled by law.
Your Employer may choose the initial treating physician. Any referral would be
			 to parties abiding by MCO rules, terms, and conditions. Emergency medical
			 treatment is exempted. If you want a change of physician, request it from the
			 Insurance Carrier or Self-Insured Employer. If the decision is unsatisfactory,
			 you may petition the Commission for a change. Pursuant to Ark. Code Ann. §
							11-9-508(e)
			 (Rpl. 1996), "[T]he 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."
Treatment or services furnished or prescribed other than
			 according to the above, EXCEPTEMERGENCY TREATMENT, shall he at your own
			 expense.