Current through Register Vol. XLI, No. 40, October 4, 2024
Section 85-21-4 - Minimum Plan Standards4.1. 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; and4. 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.4.2. A managed health care plan may include physical and vocational rehabilitation providers as part of the managed health care plan's network.4.3. This rule shall not preclude or otherwise limit an injured workers' right to seek care from a provider outside the approved plan or approved opt-out provider at his or her own expense.