099.00.97 Ark. Code R. 003
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.
099.00.97 Ark. Code R. 003