Certified managed care plans became a part of the workers' compensation system Dec. 1, 1993, and are subject to Minnesota Statutes 176.1351 and Minnesota Rules Part 5218. Specific criteria have been developed for workers' compensation certified managed care plans. The Department of Labor and Industry is authorized to certify these plans and to suspend or revoke managed care plan certifications.
Minnesota employers are allowed, but not required, to provide medical services through a network of health care providers under a certified managed care plan.
|A network of health care providers must include:|
|medical doctors, including the following specialties --
|physical and occupational therapists;|
|psychologists or psychiatrists;|
|diagnostic pathology and laboratory services;|
|radiology services; and|
|hospital, outpatient surgery and urgent care services.|
An employer must give its employees notice before they are required to receive services under a managed care plan. The notice requirements are outlined in Minnesota Rules Part 5218.0250 items A to E.
The claims adjuster's role is to work closely with the managed care plan to facilitate communication with all parties. It is important all parties are kept informed of the employee's medical recovery and ability to work. Final decisions regarding compensability of treatment are still the responsibility of the claim adjuster. These decisions should be based upon the information obtained by providers and case managers of the managed care plan, but the final payment determination is the claim adjuster's.
|The focus of workers' compensation certified managed care plans is to:|
|provide prompt evaluation and treatment;|
|encourage communication among employees, providers, qualified rehabilitation consultants (QRCs), employers and insurers;|
|educate health care providers about workers' compensation return-to-work issues;|
|provide medical care management to facilitate appropriate medical care and the employee's return to work; and|
|provide a dispute-resolution process for resolving disagreements between any of the parties about medical issues.|
The employee, insurer or health care provider cannot file a medical claim with the department unless the dispute-resolution process in the managed care plan has been exhausted.
Any referrals for services or requests for treatment to be done outside of the primary care provider's office must be through the managed care plan.
|An employee is required to treat with a health care provider in the employer's certified managed care plan unless:|
|an employee documents a history with a health care provider that maintains the employee's medical records. This requirement is presumed to be met if an employee has a documented history with a health care provider of at least two visits within the two years before the date of the injury, but other circumstances may satisfy the requirement as well.|
|an employee receives approval from either the claims adjuster or the managed care plan to treat with a provider outside the plan.|
|an employee is in need of emergency medical services.|
|an employer or insurer took part in the process of forming, owning or operating the managed care plan.|
|an employee was injured prior to the employer's selection of a managed care plan, unless the employee requests to change physicians or is referred by the primary physician for additional care.|
|an employee works or lives more than 30 miles from a plan provider in the seven-county metro area or more than 50 miles from a plan provider in greater Minnesota.|