Rule 56: Managed Care — Physicians Who Are Not Participating Physicians

A. Authorized Services. For provisions relating to choice of physician generally, see Rule 50. A physician who is not a participating physician under the managed care plan may provide services to an employee in any of the circumstances listed below under this rule if the scope of practice of the nonparticipating physician is appropriate for treatment of the injury in question.

1. A nonparticipating physician may be selected as the primary treating physician by the employee if:

a. the physician is a family physician;

b. the physician agrees to refer the employee to the managed care plan for any other treatment that the employee may require;

c. the physician agrees to comply with all of the rules, terms, and conditions of the managed care plan; and

d. the employee selects the physician as required in Rule 50,A following notice by the employer as required in Rule 50,B.

If the physician selected by the employee does not agree to refer the employee to the managed care plan for any other treatment that the employee may require or to comply with all of the rules, terms, and conditions of the managed care plan, the physician may not provide services to the employee and the employee may select another nonparticipating physician pursuant to Rule 56,A,1.

2. A nonparticipating physician may be selected as the primary treating physician by the employee if the employer does not give the employee notice, as described in Rule 50,B,2, of the right to choose a family physician as the primary treating physician.

3. A nonparticipating physician may provide services to an employee for emergency medical treatment.

4. A nonparticipating physician may deliver services to an employee when the employee is referred to such physician by the managed care plan.

5. A nonparticipating primary treating physician may be selected by the employee to provide services if there is no participating physician available within the mileage restrictions established in Rule 53,E,7, or if there is an insufficient number of participating physicians within the mileage restrictions to permit the employee to change primary treating physicians as permitted under the plan (see Rule 53,E,5); except that a nonparticipating physician may be selected in such circumstances only if no participating physician is available closer to either the residence or place of employment of the employee whose scope of practice is appropriate for treatment of the injury in question.

6. A nonparticipating physician may be selected by the employee in cases of injury requiring dismemberment or injuries involving major surgical operation to perform the operation if:

a. the physician agrees to refer the employee to the managed care plan for any other treatment that the employee may require; and

b. the physician agrees to comply with all of the rules, terms, and conditions of the managed care plan.

7. If compensability is denied by the insurer, risk management pool, or self-insured employer, the employee may leave the managed care plan and the employer shall be liable for medical, surgical, and hospital services previously provided. Under such circumstances a nonparticipating physician may be selected by the employee to provide services.

B. Change of Physician. If the employee requests a change of nonparticipating primary treating physician, further services shall be provided in accordance with Rules 53,E.

C. Disputes. Any dispute relating to the selection of a nonparticipating physician pursuant to Rule 56,A,1 through 56,A,6, as well as any dispute relating to the obligation of any nonparticipating physician to make referrals into the managed care plan or to comply with the other rules, terms, and conditions of the managed care plan shall be resolved according to the dispute resolution procedures of the managed care plan. Any nonparticipating physician who has an obligation to make referrals into the managed care plan or to comply with the other rules, terms, and conditions of the managed care plan and who fails to refer or comply, is subject to denial of payment for the related services.