| Q1: |
"What
is a managed care organization (MCO)?"
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A1:
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MCOs
are organizations certified by the director that manage
enrolled workers' medical care and services (see What
is a managed care organization?).
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| 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. |
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| 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. |
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| 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)]. |
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| 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. |
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| Q6: |
A
provider asks, "Is the insurer required to provide
me with a copy of the worker's enrollment letter?" |
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A6:
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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. |
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| 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: |
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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); |
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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: |
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Provide
a telephone number the worker may call to ask for
a written list; and |
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Tell
the worker that he or she has seven days from the
mailing date of the enrollment notice in which to
request the list; |
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Describe how the worker may get the names and addresses
of the complete panel of the MCO's medical providers;
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Describe
how the worker may receive medical services within
the MCO;
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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;
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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;
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Provide
the title, address, and telephone number of the
MCO's contact person responsible for ensuring timely
resolution of complaints or disputes;
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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;
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Notify
the MCO of any request by the worker for authorization
to treat with his or her primary care physician
or authorized nurse practitioner.
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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)].
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| 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)]. |
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| 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. |
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| 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)]. |
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| 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)]. |
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| 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.) |
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| 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.) |
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| Q14: |
A
provider asks, "How do I become a panel provider?"
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| 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)]. |
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| 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)]. |
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| 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. |
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| 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). |
