24.29.2351    REPORTING REQUIREMENTS

(1) The department finds that one of the purposes of MCOs is to control medical costs in workers' compensation cases. The department further finds that the contracts between an insurer and a MCO may contain trade secrets or proprietary information which the MCO would not voluntarily disclose to the public or competitors. The department also finds that the threat of public disclosure of trade secrets or proprietary information may tend to limit the number of MCOs that will become certified under these rules. However, in order for the department to carry out its regulatory duties, which include ensuring that a MCO is not formed, owned, or operated by an insurer, the department must obtain and review the contracts between insurers and MCOs. Because of the foregoing, the department finds that the insurer-MCO contracts required to be filed with the department pursuant to this rule carry with them a justifiable expectation of privacy, and thus the department will not make public any such contracts which contain trade secrets or proprietary information unless there is clear and convincing evidence to show that public disclosure would not constitute an unreasonable invasion of privacy. Insurers and MCOs are strongly encouraged to clearly identify which portions of their contracts contain trade secrets or proprietary information and which portions do not contain that material. The fact of the existence of a contract between an insurer and a MCO is a matter of public record.

(2) A MCO must provide to the department an executed copy of the following contracts within 10 days of signing:

(a) service contracts; and

(b) modifications to service contracts.

(3) A MCO must provide to the department an executed copy of contracts between the MCO and any entity, other than individual members of the plan and personal doctors, to perform some of the functions of the plan within 30 days of signing.

(4) A MCO must report to the department any changes in the following information within 30 days of the change:

(a) the addition or termination of members of the MCO;

(b) any change in the licensure of members or staff of the MCO;

(c) changes in the administrative staff of the MCO including, but not limited to, the liaison with the department and the day-to-day administrator of the MCO;

(d) changes in service locations; and

(e) the expiration, termination or cancellation of any service contract.

(5) The MCO must annually report to the department the following:

(a) a summary of the results of the programs implemented to promote early return to work, including the numbers of employers and injured workers involved in the cooperative effort;

(b) a summary of peer review activities describing the number of cases reviewed and the number of cases where alternative treatment strategies were recommended;

(c) a summary of utilization review activities describing the number of cases reviewed and the number of cases where different utilization strategies were recommended; and

(d) a summary of disputes which were processed through the dispute resolution procedures established by the plan. The summary must generally identify:

(i) how many disputes were raised;

(ii) the issues involved;

(iii) the relative numbers of injured workers, members, insurers or others that were involved in the disputes; and

(iv) how many of the disputes were resolved within the procedure established by the plan.

(6) The MCO must report to insurers any data regarding medical services related to workers' compensation claims which are required by the insurer to determine compensability in accordance with the Montana Workers' Compensation and occupational Disease Acts, or to comply with reporting requirements of the department.

(7) The department may require additional information from the MCO to determine if the MCO is complying with the provisions of the plan.

History: Sec. 39-71-203, 39-71-1103 and 39-71-1105 MCA; IMP, Sec. 39-71-224, 39-71-1103 and 39-71-1105 MCA; NEW, 1994 MAR p. 420, Eff. 3/1/94.