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 they have 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 the worker's primary care physician, chiropractic physician or authorized nurse practitioner who is not a member of the MCO.
- Advise the worker of their 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 the worker's 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 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.