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This depends if you meet specific subjectivity and enrollment criteria. A worker may be enrolled in an MCO if the worker has filed a claim and works for an employer that is located in the MCO's authorized geographic service area (see MCO geographic service areas) and that employer is covered by an insurer that 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.
Your employer's workers' compensation insurance company (or, if your employer is self-insured, your employer) determines if and when to enroll you 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 are represented), all your medical service providers, and to the MCO.
You are subject to the MCO when you receive actual notice of your enrollment in the MCO, or upon the third day after the insurer mails you an enrollment notice, whichever happens first.
If your family physician, including a chiropractic physician, or nurse practitioner is not an MCO member, but meets certain conditions, the MCO must authorize your provider to provide your medical treatment. Your provider must qualify under one of the following three categories:
These providers must also do all of the following:
If you have any questions or a dispute about treating with a primary care physician, chiropractic physician, or authorized nurse practitioner who is not an MCO member, you should first contact the MCO. (All disputes must first be processed through the MCO's internal dispute resolution process.)
Since April 1, 2019, you have 14 days from the date the insurer mailed you the MCO enrollment letter to obtain an authorized MCO attending physician or nurse practitioner. During this 14-day period you may continue treatment with your non-MCO provider, and the insurer is required to reimburse your non-MCO provider for services during this 14-day period if those services are otherwise compensable.
Yes, as long as it is supported by your medical record, your attending physician may advocate for you for these benefits.
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 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).
No. The insurer must send a written enrollment letter to the worker.
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.
If you want to contract with an MCO to become panel member, you need to directly contact the certified MCO. If the MCO denies your request to participate, it must provide you with a written explanation.
When you enroll a worker in an MCO, 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:
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 do the following:
If you are enrolling a worker before claim acceptance, you must inform the worker in writing that you will pay for all reasonable and necessary medical services the worker receives according to the terms and conditions 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 have mailed the denial (whichever happens first).
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 their 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, the worker's medical service provider is a nonqualified provider (not a member of the MCO and does not qualify as a primary care physician, chiropractic physician, or authorized nurse practitioner), you must inform the worker and the worker's medical providers 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 nonqualified medical provider for at least seven days after the mailing date of a completed written enrollment notice.
A worker's enrollment notice is complete under any of the following:
No. Workers are not subject to managed care contracts that expire or terminate without renewal. However, a worker may continue to treat with their 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.
Yes. No later than three days before 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.
An insurer may disenroll a worker from an MCO at any time without regard to MCO contract expiration or termination. When the insurer plans to disenroll a worker from the MCO, the insurer must mail a notice of disenrollment no later than seven days before the date the worker is no longer subject to the contract. The notice must be simultaneously provided 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.
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 want 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.)
855-350-4636 (toll-free)503-947-7606Fax: email@example.com
Para información en español 1-800-452-0288
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