A managed care organization (MCO) must have a panel of medical service providers of adequate size and variety to ensure enrolled workers receive quality medical care and services in a timely, effective, and convenient manner. The Workers' Compensation Division oversees the MCOs' compliance in the areas of treatment access and provider coverage.

Adequate access is when an enrolled worker is able to receive initial treatment by the worker's choice (from the MCO's panel of medical service providers) of an attending physician or authorized nurse practitioner within 24 hours of the MCO's knowledge of the worker's request or need for treatment. Or, when an enrolled worker is able to receive initial treatment by the worker's choice (from the MCO's panel of providers) of an attending physician or authorized nurse practitioner within five working days after treating with a physician outside the MCO.

On a 24-hour basis, MCOs must provide enrolled workers with information regarding medical services available within the MCO, including the worker's right to receive emergency or urgent care, and the MCO's regular working hours if the enrolled worker needs help in choosing an attending physician.

Enrolled workers should be able to access medical providers, including attending physicians, within a reasonable distance from the worker's place of employment, considering the normal patterns of travel.


· Adequate coverage means an enrolled worker has a choice of at least three providers within each of the required medical service provider types, as well as in ancillary care providers (for example, physical therapists and psychologists). To be authorized to operate in a Geographical Service Area (GSA), the MCO's panel of providers in that GSA must include at least three in each of the following eight required medical service provider types: acupuncturist, chiropractor, dentist, medical doctor, naturopath, optometrist, osteopath, and podiatrist. This requirement must be met unless the MCO shows evidence that a lack of a type of provider exists in the GSA and the minimum number of three is not available.

Although authorized nurse practitioners are not a required medical service provider type, MCOs must either have three on their panel in a GSA from whom the worker may choose to treat, or a process that allows the worker to treat off panel with an authorized nurse practitioner.