W. Va. Code R. § 85-21-13

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-21-13 - Injured Worker Opt-Out Standards

13.1. Injured workers may access providers who are not participating plan providers:

a. For emergency care when access to a health care provider within the managed health care plan is unobtainable for the acute phase of care;

b. When authorized treatment is unavailable through the managed care plan; or c. To obtain a second opinion when a managed health care plan physician recommends surgery and another qualified physician within the plan is not available for consultation.

13.2. Injured workers may access providers who are not participating plan providers for treatment purposes only if the injured worker has established by competent evidence all of the following:

a. The injured worker has been treated by providers solely within the employer's managed care plan for a period of at least one (1) year;

b. That for reasons related to the treatment alone, the injured worker has not made progress toward recovery that is reasonably consistent with the Commission's or upon termination of the Commission, the insurance commissioner, treatment guidelines;

c. That the injured worker establishes to a reasonable certainty that proposed treatment outside the employer's managed care plan would more likely provide the injured worker with a better clinical outcome than the current treatment or rehabilitation plan; and

d. A condition of the right to opt out under this provision shall be that the services secured outside the plan are for treatment purposes only and the provider shall not be permitted to rate the injured worker for permanent partial or permanent total disability. Any provider providing services pursuant to this provision shall be barred from providing such a rating.

W. Va. Code R. § 85-21-13