24.29.2331    CONTENTS OF THE MANAGED CARE PLAN

The managed care plan must include the following elements. A MCO is free to add additional elements, features or services beyond those described in this rule.

(1) A description of the number and specialties of persons who are eligible to be treating physicians. The following list is a minimum of the number and specialties which must be part of the plan:

(a) a minimum of five medical doctors or osteopaths, providing at least three of the following areas of practice:

(i) orthopedic;

(ii) surgery;

(iii) neurology or neurosurgery;

(iv) osteopathic treatment of musculoskeletal injury;

(v) family practice or internal medicine; and

(vi) occupational medicine or physical medicine;

(b) one chiropractor; and

(c) one dentist.

(2) A description of how the MCO will provide physical therapy services. As provided by 39-71-1105 , MCA, each MCO is encouraged to utilize the services of independent physical therapists.

(3) A description of the number and specialties of other health care providers (including, but not limited to podiatrists, physician assistants, nurse practitioners, occupational therapists, and optometrists) who will be furnishing services to injured workers.

(4) A description of how and where the following services are to be provided:

(a) in-patient surgery;

(b) out-patient surgery;

(c) radiology services, including magnetic resonance (MR) and computerized tomography (CT) imaging;

(d) psychological or psychiatric counseling;

(e) diagnostic pathology and laboratory services;

(f) hospital; and

(g) urgent care.

(5) A description of how the MCO will designate the treating physician. The description must include an explanation of how the MCO will decide which physician will be designated as the treating physician, and how the injured worker's preference of treating physician will be taken into account.

(6) A description of under what circumstances injured workers will be referred to physicians or other providers that are not members of the MCO.

(7) A description of what secondary medical services, if any, will be available.

(8) An explanation of how injured workers, once referred to MCO, will be advised of the availability of services provided by the MCO. The injured worker must be able to receive information on a 24 hour basis regarding the availability of necessary medical services provided within the MCO and information on how an injured worker can obtain emergency services or other urgently needed care. The information may be provided through recorded telephone messages after normal working hours.

(9) An explanation of how services will be provided in a timely manner.

(10) A description of how the MCO will monitor, evaluate, and coordinate the delivery by its members of quality, cost-effective medical treatment and other health services needed in the care of injured workers. The plan must adhere to any treatment standards developed by the medical advisory committees and adopted by rule by the department.

(11) A description of the program that will be used to promote an early return to work for the injured worker. The program must provide for a cooperative effort between the worker, employer, rehabilitation provider(s) , and the MCO.

(12) A description of how continuity of care will be ensured.

(13) A description of the MCO's program of peer review for services provided by its members. The peer review program must include a review of medical necessity and appropriateness of services being rendered by the health care provider in order to improve the quality of patient care and the cost-effectiveness of treatment.

(14) A description of the MCO's program for utilization review for services provided by its members. The program must include the collection, review, and analysis of group data to improve overall quality of care and efficient use of resources. The plan must adhere to any utilization standards developed by the medical advisory committees and adopted by rule by the department.

(15) A description of the financial incentives that will be implemented to reduce service costs and utilization without sacrificing the quality of services.

(16) A description of the quality assurance program to be implemented by the MCO. Such a program must include information which will allow the MCO to determine injured worker satisfaction with the level of service and care provided by the MCO. The department may forward complaints received directly from injured workers to the MCO and require the MCO to respond to the department in writing regarding issues raised in the complaints.

(17) A description of the procedure for resolving disputes, including a process to resolve disputes raised by injured workers, members, and insurers. At a minimum, the dispute resolution process must:

(a) be fair and unbiased;

(b) provide injured workers with a reasonably convenient method of presenting disputes to the MCO; and

(c) provide a written response from the MCO addressing the dispute within 15 working days of when the dispute became known.

(18) Provision for a person or persons who will act as communication liaison with the department and insurers with which the MCO contracts. The responsibilities of the liaison shall include, but are not limited to:

(a) coordinating correspondence and compliance with reporting requirements with the department;

(b) unless otherwise provided by a contract with an insurer, coordinating and channeling medical bills to insurers;

(c) unless otherwise provided by a contract with an insurer, providing centralized receipt and distribution of all reimbursements from insurers back to the MCO members; and

(d) serving as a member of the quality assurance committee.

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