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Managed care organization frequently asked questions

Workers

This depends if you meet specific subjectivity and enrollment criteria. A worker may be enrolled in an MCO if he or she 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 him or her to provide your medical treatment. Your provider must qualify under one of the following three categories:

  • Your doctor must qualify as an attending physician, be a medical doctor or osteopathic physician​, and must be a general practitioner, a family practitioner, or an internal medicine practitioner
  • Your chiropractic physician must certify with the director of DCBS
  • Your nurse practitioner must be authorized by the director to provide compensable medical services

These providers must also do all of the following:

  • 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.)
  • 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, 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).​​

Health care providers

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. ​​

Insurance companies

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:

  • 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 do the following:

  • Provide a telephone number the worker may call to ask for a written list.
  • 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, chiropractic 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 timelines 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, chiropractic physician or authorized nurse practitioner.

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 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 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 his or her 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:

  • 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.
  • 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.
  • On the date you mailed the written list of the MCO's eligible attending physicians to the worker when you have 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.
​​

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.​​

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.)​​

Contact

855-350-4636 (toll-free)
503-947-7606
Fax: 503-947-7629
wcd.medicalquestions@oregon.gov​​​​​

Para información en español
1-800-452-0288​​​

Receive updates on health care provider information​​​​​​

800-452-0288 (toll-free)
503-947-7840
workcomp.questions@oregon.gov

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