Rule 53: Managed Care — Requirements for Certification

Words in italics are defined in Rule 49.

A. In order to become and remain certified under these rules, a managed care plan must meet all the requirements of Rule 51 through Rule 61 as well as those listed in section 48-120.02.

B. The managed care plan must ensure provision of quality health care services that meet all uniform treatment standards adopted by the plan or which may be prescribed by the court, and all health care services that may be required under the Nebraska Workers’ Compensation Act in a manner that is timely, effective and convenient for the employee. The employer shall remain liable for any health care service required under the Act that the managed care plan does not provide.

C. The managed care plan must have contracted for, at a minimum, the following types of health care services and providers, unless the managed care plan is unable to contract for a particular service or type of provider. If the managed care plan is unable to contract for a particular service or provider, then the managed care plan shall provide an explanation. The managed care plan must provide to an employee at a minimum, when necessary, the following types of health care services and providers:

1. medical doctors in at least one of the following specialized fields: family practice, internal medicine, occupational medicine, physiatry or emergency medicine;

2. orthopedic surgeons;

3. specialists in hand and upper extremity surgery;

4. neurologists;

5. neurosurgeons;

6. general surgeons;

7. chiropractors;

8. podiatrists;

9. osteopaths;

10. dentists;

11. dermatologists;

12. ophthalmologists;

13. optometrists;

14. physical therapists;

15. occupational therapists;

16. psychologists;

17. psychiatrists;

18. diagnostic pathology and laboratory services;

19. radiology services;

20. hospital services;

21. outpatient surgery; and

22. urgent care services.

D. The managed care plan must provide for referral for any services that are not specified above in Rule 53,C that are required under the Nebraska Workers’ Compensation Act.

E. The managed care plan must include procedures to ensure that employees will receive health care services in accordance with the following:

1. Employees must receive initial evaluation by a participating licensed physician in one of the disciplines listed below in Rule 53,E,3 within 24 hours of the employee’s request to the managed care plan for treatment following an injury. The managed care plan may select the physician to do the evaluation.

2. In cases where the employee has received treatment for the work injury by a physician outside the managed care plan under Rule 56,A,1 or Rule 56,A,6 the employee must receive initial evaluation or treatment by a participating licensed physician within five working days of the employee’s request for a change of doctor, or referral to the managed care plan. The managed care plan may select the physician to do the evaluation.

3. Following the initial evaluation and upon request, the employee must be allowed to choose to receive ongoing treatment from any one participating physician in one of the disciplines listed below as the primary treating physician, if the physician is available within the mileage limitations established in Rule 53,E,7, if the treatment is required under the Nebraska Workers’ Compensation Act, if the treatment is within the provider’s scope of practice, and if the treatment is appropriate under the standards of treatment adopted by the managed care plan:

a. medical doctors;

b. chiropractors;

c. podiatrists;

d. osteopaths; or

e. dentists.

An evaluating physician may also be offered as a primary treating physician.

The primary treating physician may arrange for any consultation, referral, or extraordinary or other specialized medical services as the nature of the injury shall require, as permitted under the managed care plan.

4. Employees must receive any required treatment, diagnostic tests, or specialized medical services in a manner that is timely, effective, and convenient for the employee.

5. Employees must be allowed to change primary treating physicians within the managed care plan at least once by making application for such change to the plan without proceeding through the managed care plan’s dispute resolution process. A change of physician from the evaluating physician to a primary treating physician for ongoing treatment is not considered a change of physician, unless the employee has received treatment from the evaluating physician more than once for the injury.

6. Employees must be able to receive information at no cost on a 24-hour basis regarding the availability of health care services under the managed care plan. The information may be provided through recorded telephone messages after normal working hours. The message must include information on how the employee can obtain emergency services or other urgently needed care, and how the employee can receive an evaluation.

7. Employees must have access to the evaluating and primary treating physician within 30 miles of either the employee’s place of employment or residence if either the residence or place of employment is within a city with a population of 5,000 or more. If both the employee’s residence and place of employment are outside a city with a population of 5,000 or more, the allowable distance is 60 miles. If the primary treating physician is not available within the stated mileage restrictions then a nonparticipating physician may be selected pursuant to Rule 56,A,5.

F. The managed care plan must designate the procedures for approval of services from a physician outside the managed care plan as permitted in Rule 56,A,1 through Rule 56,A,6, and how such physician will be informed of the rules, terms, and conditions of the managed care plan, and the procedures for referring an employee to the managed care plan for any other treatment that the employee may require.

G. The managed care plan must include a procedure for peer review and utilization review as specified in Rule 59.

H. The managed care plan must include a procedure for internal dispute resolution as specified in Rule 58.

I. The managed care plan must describe how employers, insurers, and risk management pools will be provided with information that will inform employees of all choices of physician under the plan and how employees can gain access to those physicians. The plan must submit a proposed notice to employees, which may be customized according to the needs of the employer, but which must include the information required by Rule 55.

J. The managed care plan must describe how aggressive medical case management will be provided as specified in Rule 60, and how a program for early return to work and cooperative efforts to promote workplace health and safety consultative services will be provided.

K. The managed care plan must describe a procedure or program through which health care providers may obtain information on the following topics:

1. treatment parameters adopted by the plan;

2. maximum medical improvement;

3. permanent partial impairment rating;

4. return to work and disability management;

5. health care provider obligations in the workers’ compensation system; and

6. other topics the managed care plan deems necessary to obtain cost effective, quality medical treatment and appropriate return to work for an injured employee.

The medical director or designee must be available as a consultant on the topics listed above in Rule 53,K,1 through Rule 53,K,6 to any health care provider delivering services under the managed care plan.

L. The managed care plan must describe the treatment standards it has adopted or developed, if any, for health care services that are to be used in the treatment of workers’ compensation injuries. All participating health care providers and those nonparticipating providers subject to the rules, terms and conditions of the managed care plan shall be governed by such treatment standards. This paragraph does not, however, require ongoing treatment in individual cases if the treatment is not medically necessary, even though the maximum amount of treatment permitted under any standard has not been given.

M. The managed care plan may contract for payment of medical, surgical, and hospital services under the plan at fees different from those established by the Diagnostic Related Group inpatient hospital fee schedule established in section 48-120.04 or a fee schedule adopted by the court pursuant to Rule 26.

N. The managed care plan must maintain a standardized claimant medical recordkeeping system designed to facilitate entry of information into computerized databases.

O. The managed care plan must provide a timely and accurate method of reporting to the court necessary and useable information regarding medical, surgical, and hospital service cost and utilization to enable the court to determine the effectiveness of the plan.

P. The managed care plan must maintain and provide to the court on request any other information or data as the court considers necessary.