West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-4 - Minimum Plan Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				Employers, managed health care plans acting on their behalf, private carriers,
				or third party administrators may submit to the Commission, or upon termination
				of the Commission, the insurance commissioner, a proposed managed health care
				plan and if approved, can require its injured workers to use health care
				providers authorized by the managed health care plan for care and treatment of
				the injured workers' compensable injuries. The Commission, or upon termination
				of the Commission, the insurance commissioner, retains sole discretion in
				approving proposed managed health care plans. All managed health care plans
				submitted for approval shall include the following features:
a. Co-payments or deductibles shall not be
				required for medical services rendered in connection with a work-related injury
				or occupational disease;
b. The
				injured worker shall be allowed a reasonable choice of providers within the
				plan;
c. Adequate specialty and
				subspecialty providers, and general and specialty hospitals must be provided
				for to afford employees reasonable choice and convenient geographic
				accessibility to all categories of licensed care. Primary care available within
				75 driving miles of the employer's facility is presumed to be geographically
				reasonable unless the standard of care within the community extends this
				distance. The availability of secondary and tertiary care shall not be governed
				by the 75 mile standard;
d. The
				managed health care system shall provide an informal procedure for the
				expeditious resolution of disputes concerning rendition of medical
				services;
e. The employee shall be
				allowed to obtain a second opinion, at the employer's expense, from a qualified
				physician within the plan, if available, if a managed health care system
				physician recommends surgery;
f.
				The managed health care system shall establish procedures for utilization
				review of medical services to assure that a course of treatment is medically
				necessary; diagnostic procedures are not unnecessarily duplicated; the
				frequency, scope, and duration of treatment is appropriate; pharmaceuticals are
				not unnecessarily prescribed; and that ongoing and proposed treatment is not
				experimental, cost ineffective, or harmful to the employee;
g. Mechanisms for utilization review which
				shall prevent inappropriate, excessive, or medically unnecessary medical
				services and including:
1. Treatment
				standards upon which utilization review decisions shall be based (including low
				back symptoms and injuries to the upper extremities and knees) assuring quality
				care in accordance with prevailing standards in the medical community of which
				the plan provider is a member. The standards shall conform to any practice
				parameters or guidelines for clinical practice adopted by the Commission, or
				upon termination of the Commission, the Insurance Commissioner;
2. Mechanisms requiring periodic review to
				determine that continued treatment of an injured employee is reasonable,
				appropriate, and medically necessary;
3. Assurance that the managed health care
				system is conducting utilization review; and
4. Adequate procedures for credentialing
				providers and evaluating the quality and cost effectiveness of services
				delivered under the plan.
h. Statements for services shall be audited
				regularly to assure that charges are not duplicated and do not exceed those
				authorized by the particular plan;
i. Restrictions on provider selection imposed
				by a managed health care plan authorized by this chapter shall not apply to
				emergency medical care;
k.
				Provisions to allow for the Commission, or upon termination of the Commission,
				the insurance commissioner, to audit the managed health care plan's
				operations;
l. Effective methods of
				informing employees, employers, and medical providers of the services provided
				by the plan and requirements imposed by the plan, including a twenty-four (24)
				hour toll free phone number by which information may be obtained concerning
				plan operations, after-office-hours care, and twenty-four (24) hour access to
				emergency care;
m. A system to
				provide authorization to medical providers and health facilities where
				preauthorization or continued stay review is required by the plan. The
				authorization shall be recorded in the treatment section of the appropriate
				billing forms;
n. Case management
				by either a certified case manager, certified rehabilitation counselor,
				certified insurance rehabilitation specialist, or a certified rehabilitation
				registered nurse to coordinate the delivery of health services and return to
				work policies; promote an appropriate, prompt return to work; and facilitate
				communication between the employee, employer, and health care providers. The
				plan shall describe the circumstances under which injured employees shall be
				subject to case management and the services to be provided;
o. The managed health care plan must be owned
				and operated by an organization or entity sufficiently unrelated and
				independent of the employer in terms of ownership and control so that it can
				demonstrate independence from said employer; and p. The managed health care
				plan shall have a medical director to fulfill the duties set forth in this
				exempt legislative rule and to perform other duties customarily associated with
				the medical director of a managed health care plan.