Arkansas Administrative Code › Agency 099 - Arkansas Workman's Compensation › Rule 099.00.97-001 - 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/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
		  pasted 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.
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, or self-insured
		  employers has been suspended by the Arkansas Workers' Compensation Commission
		  for a period of time.
B.
INITIAL CHOICE OF PHYSICIAN
An employer shall have the right to choose the initial treating
			 physician. If the employer so chooses the employer shall 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). 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
			 health care 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)
			 the claimant employee, however, may petition the Commission one (1) time only
			 for a change of physician, who must also either be associated with a managed
			 care entity certified by the Commission or is the regular treating physician of
			 the employee so long as the health care provider agrees to refer the employee
			 to a certified managed care entity for any specialized treatment, including
			 physical therapy, and only if such health care provider agrees to comply with
			 all the rules, terms and conditions regarding services performed by the managed
			 care entity initially chosen by the employer.
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, 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/lMCS
Rules, terms, and conditions shall be made available upon request
			 by the Arkansas Workers' Compensation Commission.