099.00.99 Ark. Code R. 002
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 :
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.
For the purpose of this rule, unless the context requires otherwise:
"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.
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.
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.
When approving a change of physician, the Commission may authorize a nonparticipating provider/physician to provide services to a worker if:
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.
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.
Rules, terms, and conditions shall be made available upon request by the Arkansas Workers' Compensation Commission.
The medical director of an MCO must document attendance for a minimum of six (6} hours of education during the first year, and three (3) hours each year thereafter, covering any of the topics listed in items (1) to (6) above. The documentation shall be submitted to the Administrator upon request. The medical director or designee must be available as a consultant on these topics to any health care provider delivering services under the MCO.
A medical case manager shall monitor, evaluate, and coordinate the delivery of quality, cost effective medical treatment and other health care services needed by an injured employee. Medical case managers should ensure that the injured or disabled employee is following the prescribed medical care plan, and shall promote an appropriate, prompt return to work. Medical case managers shall facilitate communication between the employee, employer, insurance carrier/self-insured, health care provider, managed care plan, and any assigned vocational rehabilitation counselor to achieve these goals.
A medical case manager for the purposes of this Rule means an individual who provides or supervises the provision of medical case management services under the MCO and who is either:
I n order to maintain certification, each IMCS shall provide within thirty (30) days following each anniversary of certification the following information:
Disputes, other than choice and change of physician, which arise on an issue related to managed care, such as the question of inappropriate, excessive, or not medically necessary treatment, medical disputes, disputes regarding non-participating providers, etc., between the employee, health care provider, managed care plan, insurance carrier/self-insured employer, or employer shall first be processed without charge to the employee or health care provider through the dispute resolution process of the MCO/IMCS. Disputes must be in writing and filed within thirty (30) days of the dispute. The MCO/IMCS dispute resolution process must be completed within thirty {30} days of receipt of a written request. If the dispute cannot be resolved, or one of the parties so requests in writing, the Administrator shall assist in resolution pursuant to the administrative review process as set out below. For change of physician see Part I, D (page 3) of this rule. For choice of physician see Part I, B (page 2) of this rule.
The process for. administrative review of such matters shall be as follows:
The appealing party shall mail a copy of all materials which are filed in the appeal to each opposing party. No response to the appeal of the Administrator's order is required. A decision must be entered by the Administrator or Administrator's designee before any appeal may be brought.
An order or award of an Administrative Law Judge shall become final unless a party to the dispute shall, within thirty (30) days from the receipt by him of the order or award, petition in writing for a review by the Full Commission of the order or award. See Ark. Code Ann. § 11-9-711(a) (1) (1987).
An order or award of the Commission shall become final unless a party to the dispute shall, within thirty (30) days from receipt of the order or award, file notice of appeal to the Court of Appeals. See Ark. Code Ann. § 11-9-711(b) (1987).
Any amendments and/or changes to the certified MCO/IMCS plan must be approved by the Administrator before becoming effective.
(Adopted July 1, 1994; Revised Effective January 20, 1997)
(Adopted Ocotber 26, 1999; Revised effective November 15, 1999.)
099.00.99 Ark. Code R. 002