Q1:

"What is a managed care organization (MCO)?"

A1:

MCOs are organizations certified by the director that manage enrolled workers' medical care and services (see What is a managed care organization?).

Q2:

A worker asks, "Can I be enrolled in an MCO?"

A2:

This depends if you meet specific subjectivity and enrollment criteria (see Subjectivity and enrollment of injured workers). A worker may be enrolled in an MCO if he or she has filed a claim and works for an employer who is located in the MCO's authorized geographic service area (see MCO geographical service areas) and that employer is covered by an insurer who has a contract with the MCO. However, be aware that "notice is the key." A worker cannot be required to treat within an MCO unless provided proper and complete written notice by the insurer or self-insured employer.

Q3:

A worker asks, "Who enrolls me into an MCO?"

A3:

Your employer's workers' compensation insurance company (or, if your employer is self-insured, your employer) determines if and when to enroll you [see ORS 656.245(4)(a)] into its contracted MCO. The insurer or self-insured employer must send you a written enrollment letter and, at the same time, provide a copy of your enrollment letter to your attorney (if you're represented), all your medical service providers, and to the MCO.

Q4:

A worker asks, "When am I subject to an MCO?"

A4:

You are subject to the MCO when you receive your written enrollment letter from the insurer, or upon the third day after the insurer mails it to you, whichever first occurs [ORS656.245(4)(a)].

Q5:

A provider asks, "Can an insurer enroll a worker in an MCO by a telephone call?"

A5:

No. The insurer must send a written enrollment letter to the worker.

Q6:

A provider asks, "Is the insurer required to provide me with a copy of the worker's enrollment letter?"

A6:

Yes. The insurer must provide a copy of the enrollment letter to all the worker's medical service providers, the worker's attorney (if represented), and the MCO at the same time it mails the letter to the worker.

Q7:

The insurer asks, "What information do we have to include in a worker's enrollment notification?"

A7:

When you enroll a worker into an MCO [see ORS 656.245(4)(a), OAR 436-010-0275(4) - (8), and OAR 436-015-0035(4)(e)(A)], you must simultaneously notify the worker, the worker's representative, all medical service providers, and the MCO of the worker's enrollment. Your enrollment notice must:
	Provide the worker with a written list of MCO eligible attending physicians within the MCO's relevant geographic service area or provide a Web address for the worker to access the list of the MCO's eligible attending physicians (see When an enrollment notice is complete);

	If you provide only a Web address and do not enclose a written list of the MCO's eligible attending physicians, then your enrollment notice must also:
		Provide a telephone number the worker may call to ask for a written list; and
		Tell the worker that he or she has seven days from the mailing date of the enrollment notice in which to request the list;

	Describe how the worker may get the names and addresses of the complete panel of the MCO's medical providers;

	Describe how the worker may receive medical services within the MCO;

	Describe how a worker may receive medical treatment from his or her primary care physician or authorized nurse practitioner who is not a member of the MCO;

	Advise the worker of his or her right to choose the MCO if you have more than one MCO contract covering the worker's employer;

	Provide the title, address, and telephone number of the MCO's contact person responsible for ensuring timely resolution of complaints or disputes;

	Advise the worker of the time lines for appealing disputes beginning with the MCO's internal dispute resolution process through administrative review before the director, that disputes must be in writing to the MCO and filed within 30 days of the disputed action, with whom the dispute is to be filed, and that failure to request review by the MCO precludes further appeal;

	Notify the MCO of any request by the worker for authorization to treat with his or her primary care physician or authorized nurse practitioner.

If you are enrolling a worker prior to claim acceptance [ORS 656.245(4)(b)(B)], you must inform the worker in writing that you will pay [as provided in ORS 656.248] for all reasonable and necessary medical services received by the worker that are not otherwise covered by health insurance, even if you deny the worker's claim, until the worker receives your denial or until three days after you've mailed the denial (whichever first occurs). When you are enrolling a worker who is not yet medically stationary and you are requiring the worker to change to an MCO provider, you must inform the worker of his or her right to request a review by the MCO if the worker believes changing providers would be medically detrimental. If, at the time you are enrolling the worker, his or her medical service provider is a non-qualified provider (not a member of the MCO and doesn't qualify as a primary care physician or authorized nurse practitioner), you must inform the worker and his or her medical provider(s) regarding the provision of care under the MCO contract, including continuity-of-care provisions. This includes the worker's right to continue to treat with the non-qualified medical provider for at least seven days after the mailing date of a completed written enrollment notice [OAR 436-010-0275(8)(a)-(c) and 436-015-0035(4)(e)(A)].

Q8:

The insurer asks, "When is an enrollment notice complete?

A8:

A worker's enrollment notice is complete:

On the date you mailed the enrollment notice to the worker and it contains all required enrollment information and a written list of the MCO's eligible attending physicians; or

On the date you mailed the enrollment notice to the worker and it contains all required enrollment information and a Web address for the worker to access the MCO's list of eligible attending physicians and the worker does not request a written list within seven days from the date you mailed the enrollment notice; or

On the date you mailed the written list of the MCO's eligible attending physicians to the worker when you've provided all required enrollment information in the worker's enrollment letter and a Web address for the worker to access the list of the MCO's eligible attending physicians and the worker requested the written list from you within seven days from the date you mailed the worker's enrollment letter [OAR 436-010-0275(8)(a)-(c)].

Q9:

The worker asks, "My provider is not an MCO panel provider and does not qualify to continue to treat me as my Primary Care Physician or Authorized Nurse Practitioner. How long can I continue to treat with my provider (and the insurer is required to reimburse my provider) after I've requested the insurer to mail me a written list of the MCO's eligible attending physicians? I asked the insurer to mail me the written list within seven days from the date the insurer mailed my enrollment letter."

A9:

If, within seven days from the date the insurer mailed you your enrollment letter, you asked the insurer to mail you the written list of the MCO's eligible attending physicians, you may continue to treat with your non-MCO provider for up to seven days from the date the insurer mails you the written list. The insurer is required to reimburse your non-MCO provider for up to seven days from when the insurer mailed you the written list of the MCO's eligible attending physicians (as long as you timely requested the list). If, more than seven days from the date the insurer mailed you your enrollment letter, you asked the insurer to mail you the written list of the MCO's eligible attending physicians, the insurer is required to reimburse your non-panel provider for up to seven days from the date the insurer mailed you your enrollment letter that contains all required (see enrollment letter) enrollment information.

Q10:

The insurer asks, "Are workers subject to expired or terminated managed-care contracts?"

A10:

No. Workers are not subject to managed-care contracts that expire or terminate without renewal. However, a worker may continue to treat with his or her attending physician or authorized nurse practitioner under an expired or terminated managed-care contract if that physician or authorized nurse practitioner agrees to comply with the rules, terms and conditions under any subsequent managed-care contract to which the worker is subject [ORS 656.245(4)(a)].

Q11:

The insurer asks, "Do we have to inform workers when they are no longer subject to a managed-care contract?"

A11:

Yes. No later than three days prior to the contract's expiration or termination date, an insurer must simultaneously provide written notice to the worker, the worker's representative, all medical service providers, and the MCO, that the worker is no longer subject to the managed-care contract. You must also inform the worker of the manner in which the worker may receive medical services after the worker is no longer subject to the contract [OAR 436-010-0275(13)].

An insurer may disenroll a worker from an MCO even when a contract is not expired or terminated. In this case, no later than seven days prior to the date the worker is no longer subject to the contract, the insurer must simultaneously provide written notice of disenrollment to the worker, the worker's representative, all medical service providers, and the MCO. The insurer must also inform the worker of the manner in which the worker may receive compensable medical services after the worker is no longer enrolled [OAR 436-010-0275(12)].

Q12:

A worker asks, "If I am enrolled in an MCO, can I treat with my family doctor or nurse practitioner?"

A12:

If your physician or nurse practitioner is not an MCO member, but meets certain conditions, the MCO must authorize him or her to provide your medical treatment [ORS 656.260(4)(g), ORS 656.245(5) and OAR 436-015-0070].

Your doctor must qualify as an attending physician [ORS 656.005(12)(b)(A)], be a medical doctor or doctor of osteopathy, and must be a general practitioner, a family practitioner, or an internal medicine practitioner.

Your nurse practitioner must be authorized by the director to provide compensable medical services.

These providers must also:

Maintain your medical records;

Have a documented history of treating you prior to your injury;

Agree to comply with all the MCO's terms and conditions for medical services. ("Terms and conditions" means the MCO's treatment standards, utilization review, peer review, dispute resolution, billing and reporting procedures, and fees for services); and

Agree to refer you to the MCO for any other specialized care that you may require (such as physical therapy) to be furnished by another provider.

If you have any questions or a dispute about treating with a primary care physician or authorized nurse practitioner who is not a MCO member, you should first contact the MCO. (All disputes must first be processed through the MCO's internal dispute resolution process.)

Q13:

The insurer or self-insured employer asks, "How can my company contract with an MCO?"

A13:

Only insurance companies and self-insured employers can contract with Certified MCOs. The MCO must be authorized to operate in your employer's geographic service area location. If you wish to contract with a specific MCO, you will need to contact that MCO directly to discuss a contracting agreement. (To see a complete listing of current MCO/insurer and self-insured employer contracts see MCO contracts.)

Q14:

A provider asks, "How do I become a panel provider?"

A14:

If you want to contract with an MCO to become panel member, you will need to contact the Certified MCO directly. If the MCO denies your request to participate, they must provide you with a written explanation [ORS 656.260(4)(h)].

Q15:

A worker asks, "Can my MCO doctor be my advocate for my medical services and temporary disability benefits (timeloss)?"

A15:

Yes, as long as it is supported by your medical record, your attending physician may advocate for you for these benefits [ORS 656.260(4)(i)].

Q16:

A worker asks, "Can I appeal the MCO's medical decisions?"

A16:

Yes. When an MCO disapproves a requested medical service, or you do not agree with the MCO decision, you can appeal that decision. The MCO must include dispute resolution information (OAR 436-015-0110) in its decision and must provide written notice of its decision to all parties that can appeal the decision. If the MCO receives a complaint or dispute that is not included in its dispute resolution process, the MCO must, within seven days of receiving the complaint, provide you with written notice of your right to request review by the director.

If a worker, medical provider, or insurer/self-insured employer has questions or complaints about the MCO's medical management services, they should first contact that MCO (see Certified MCO listing).

If you have questions about the information contained in this document, please contact Tony Guidone, (503) 934-6018 or Sandra Savage, (503) 934-6023.