CHAPTER
Lab 700 MANAGED CARE PROGRAMS IN
WORKERS’ COMPENSATION
Statutory
Authority: RSA 281-A: 23-a, V and VI (b), RSA 281-A:60, I (a) and (p)
PART
Lab 701 PURPOSE AND APPLICABILITY
Lab 701.01 Purpose. This chapter sets forth the rules which
govern the implementation of RSA 281-A:23-a pertaining to the approval and use
of managed care programs in workers' compensation.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 701.02 Applicability. These rules shall apply to all managed care programs
upon adoption.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
PART
Lab 702 DEFINITIONS
Lab 702.01 “Healthcare provider” means a hospital,
physician or medical specialist offering services within the managed care
system.
Source.. #5788, eff 2-17-94; amd
by #7143, eff 11-24-99; amd by #7212, INTERIM, eff
3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 702.02 “Independent medical examination” means a medical
examination conducted by a qualified healthcare provider at the request of
either the injured employee or insurance carrier solely for the purpose
of determining compensability, degree of disability or degree of impairment
arising from the injury.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss and moved by #9217, eff
8-1-08 (from Lab 702.02); ss by #12013, eff 10-25-16 (from Lab 702.03)
Lab
702.03 “Injury management facilitator” means an individual employed by, or contracted as a worker for payment by,
a managed care organization, and approved by the department of labor and
workers' compensation advisory council using criteria specified in Lab
703.01(m) to provide case management services to injured workers receiving
services within a workers' compensation managed care system.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss and moved by #9217, eff
8-1-08 (from Lab 702.03); ss by #10038, eff 12-1-11; ss by #12013, eff 10-25-16
(from Lab 702.04)
Lab 702.04 “Managed care organization” means an
organization which coordinates medical services for workers' compensation cases
in accordance with RSA 281-A:23-a.
Source.. #7338, eff 8-2-00; ss and moved by #9217, eff
8-1-08 (from Lab 702.04); ss by #12013, eff 10-25-16 (from Lab 702.05)
Lab 702.05 “Network” means a system of healthcare
providers, contracted by a managed care organization, to render services, as
needed, to workers' compensation injured employees unless a different
definition is specified.
Source.. #7338, eff 8-2-00; ss and moved by #9217, eff
8-1-08 (from Lab 702.05); ss by #12013, eff 10-25-16 (from Lab 702.06)
Lab 702.06 “Protocol” means the medical guidelines established
by a managed care organization to which a healthcare provider, wishing to
provide services within a managed care program, agrees to comply.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16 (from Lab 702.07)
Lab 702.07 “Second opinion” means a medical examination
conducted by a qualified healthcare provider at the request of an injured
employee within a managed care network solely for the purpose of
determining or confirming a diagnosis or the proper course or treatment for the
injuries.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16 (from Lab 702.08)
Lab 702.08 “Workers' compensation advisory council”
means the council established in accordance with RSA 281-A:62.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16 (from Lab 702.09)
PART
Lab 703 MANAGED CARE PROGRAM CRITERIA
AND APPROVAL PROCESS
Lab 703.01 Necessary Components.
(a)
No managed care program in workers' compensation shall be offered or
used in this state unless the commissioner finds that the program meets the
requirements of (b)-(p) below.
(b)
The network of health care providers shall be sufficiently comprehensive
with respect to both geography and medical specialties.
(c)
A network shall be deemed comprehensive if it includes 2 or more
vocational rehabilitation providers, for injuries covered by the program.
(d)
A network of health care providers shall be sufficiently comprehensive
with respect to geography and medical specializations when the commissioner
finds that it offers a covered employee in each county a choice of 2 or more of
each of the following health care providers:
(1) Chiropractic services;
(2) Family practice or occupational medicine physicians or internal medicine physicians;
(3) Neurologists;
(4) Neurosurgeons;
(5) Ophthalmologists;
(6) Occupational therapists:
(7)
Physical therapists;
(8) Orthopedic surgeons;
(9) Physiatrist or rehabilitation medicine
physicians; and
(10) Spine surgeons.
(e)
In cases where 2 or more of such choices are not available in each
county covered by the proposed network, the program shall be considered
comprehensive if it allows access to such medical services in an adjacent
county.
(f)
The program may include additional healthcare providers and medical
services other than those listed in part (d) above, provided the injured
employee has a choice of at least 2 such providers within the radius of 25
miles from the injured employee’s residence.
An injured employee shall be required to use as part of the network only
those health care providers.
(g)
The program shall provide for treatment and remedial services, nursing,
medicines and mechanical and surgical aids outside of the network under the
following circumstances:
(1) If the necessary services or aids are not
available to the employee within the network, or if emergency circumstances
prohibit use of the network;
(2) When transfer of care outside the network is
recommended by an in-network provider, the reasonableness of future treatment
shall be determined by reviewing the physician's recommendations and the
network's availability to assist the employee in obtaining the needed services
and aids within the network;
(3) If emergency circumstances in which treatment
or aids required to protect the health of an injured employee are required to
be applied or administered immediately and without opportunity to notify the
person or persons designated for such notification by the program or to follow
the directive of such person or persons if such notification occurred;
(4) If an injured employee has been treated by a
provider who is not a member of the network to treat a recurrence or
aggravation of an injury treated by such provider within the prior 6 months, as
long as such provider complies with all the terms, conditions, protocols,
referral procedures, and levels of reimbursement established by the network; or
(5)
If unique circumstances based upon an individual case are sent in writing to
the commissioner showing that the requested services or aids were not available
within the network the commissioner shall investigate the circumstances and the
network's resources to determine if it is necessary to seek out of network
services and shall advise the parties of the decision.
(h)
The program shall include a process for determining professional
qualifications of health care providers in the network. Internal credentialing
procedures shall be sufficient, as long as the data utilized in the process of
credentialing shall be in enough detail to enable the commissioner to verify
the validity of the process.
(i) The
program shall provide for acceptable quality assurance measures. Acceptable quality assurance measures means
regularly utilized procedures to assure that medical providers shall be
continually qualified by training and experience to administer the treatment or
aids offered to covered employees. Additionally, following such treatment and
aids, medical records shall be retained and available for inspection. These measures shall include the use of a
quality assurance committee which regularly inspects such evidence or records
and the quality of care being delivered by the program.
(j)
The program shall include both in-patient and out-patient case management,
medical, vocational and rehabilitation case management that includes
prospective and concurrent review, discharge planning, work-hardening and
return to work programs. The program
shall include a sufficient number of injury management facilitators who
shall be qualified by reason of education, experience and training to manage an
injured employee's medical care by interacting with the employee, treating
physician, other healthcare providers and the employer to facilitate the
expeditious intervention of medical treatment and an early return to work.
(k)
Each managed care organization shall have a sufficient number of injury
management facilitators. This number shall include at least one resident
injury management facilitator with a business office in New Hampshire.
(l) In determining what constitutes a
sufficient number of injury management facilitators, the following shall be
used to determine compliance:
(1) The number of employers subscribing to the
program:
(2) The approximate number of employees covered
by the program; and
(3) The average number of cases referred to each
injury management facilitator annually.
(m)
At least one in every 5 injury management facilitators shall be a resident injury
management facilitator with a business office in New Hampshire.
(n)
Injury management facilitators employed or contracted by the
managed care organization shall be qualified, with such qualification valid for only 5 years and subject to
requalification an unlimited number
of times, in one or more of the following ways:
(1) By holding a license as a registered nurse
issued by the New Hampshire board of nursing and having at least one year of
experience in the medical management of workers' compensation claims in
New Hampshire or in lieu of experience has completed a training program
offered by the department;
(2) By holding a designation as a certified case
manager issued by The Commission on Case Manager Certification, and having at
least one year of experience in the medical management of workers'
compensations claims in New Hampshire or in lieu of the experience has
completed a training program offered by the department;
(3) By holding a designation as a certified
rehabilitation counselor issued by The Commission on Rehabilitation Counselor
Certification, and having at least one year of experience in the medical
management of workers' compensation claims in New Hampshire or in lieu of the
experience has completed a training program offered by the department; or
(4) By holding a designation as a certified
disability management specialist issued by The Commission on Disability
Management Specialists, and having at least one year of experience in the
medical management of workers' compensation claims in New Hampshire
or in lieu of the experience has completed a training program offered by
the department.
(o)
The program shall provide an employee with access to a second medical
opinion, inside or outside the program, regarding diagnosis or the proper
course of treatment, and adequate methods for resolving conflicting medical
opinions. Access to a second medical
opinion shall be warranted when following an examination and diagnosis by a
medical provider, the employee remains uncertain about the nature of the injury
or the proper course of treatment necessary to cure or alleviate it.
(p) The program shall provide a method
for prompt and impartial resolution of questions or disagreements between a
healthcare provider and the managed care organization.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08; amd by #10038, eff 12-1-11; ss by#12013, eff 10-25-16
Lab 703.02 Filing.
(a)
A proponent of a managed care program in workers' compensation shall
file a complete description of the program with the commissioner, who shall
review the filing for compliance with the provisions of RSA 281-A:23-a and Lab
703.01.
(b)
The filing shall include all information deemed by the proponent to be
relevant to a determination of compliance hereunder, including as a minimum the
following:
(1) The name and business address of all health
care providers included in the network as required in Lab 703.01(d);
(2) A description of the program's procedure
establishing compliance with Lab 703.01(g);
(3) A description of the program's treatment protocols;
(4)
A description of the program's in-patient and out-patient case management
programs establishing compliance with Lab 703.01(j);
(5) A description of the program's procedures
establishing compliance with Lab 703.01(o);
(6) Sample employee information material
establishing compliance with Lab 704.02(a)(1); and
(7) Any further information requested by the
commissioner in order to determine whether the proposed managed care program
complies with the provisions of RSA 281-A:23-a and this chapter.
(c) The format of
filing shall include a printed spreadsheet of healthcare providers in the
network with columns for county, specialty and provider, and an alphabetical
listing at the end with all the providers for each county.
(d) The geographic area for which the proponent
seeks approval of the managed care program shall be the entire state of New Hampshire.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 703.03 Commissioner Approval Process.
(a)
After a review of the managed care program, if the commissioner
determines a program filed under Lab 703.02 is in compliance, the commissioner
shall approve it and provide written notice of such approval to the proponent.
(b)
Any program filed under Lab 703.02 shall be deemed approved by the
commissioner, unless within 45 days after its filing, the commissioner makes a
preliminary determination of noncompliance, specifying in writing the reasons
why the program does not comply with RSA 281-A:23-a and Lab 703.01.
(c)
If the commissioner determines that the managed care program does not
meet the criteria set forth in RSA 281-A:23-a and Lab 703.01, the commissioner
shall advise the applicant in writing and specify which criteria have not been
met.
(d)
The proponent of such program shall have the right to a hearing before
the commissioner or the commissioner's authorized representative to contest the
preliminary determination.
(e)
Upon a preliminary determination approving the program by the
commissioner, the proponent shall provide a copy of the program to each member
of the advisory council no later than 14 days prior to the next regularly
scheduled meeting at which the program is to be acted upon.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 703.04 Advisory Council Process.
(a)
A managed care program approved or deemed approved by the commissioner
under Lab 703.03 shall be submitted to the advisory council.
(b)
Upon receipt of the program, the council shall take the following
action:
(1) Consider the ratification of the program at
its next regularly scheduled meeting no fewer than 19 days following the commissioner's
approval;
(2) Either approve the program or specify its
reasons why the program does not meet the requirements of RSA 281-A:23-a and
Lab 703.01 in writing; and
(3) Provide the program proponents with the opportunity
for a hearing before the council to appeal the non-ratification.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 703.05 Duration of Approval and Review.
(a) Upon its first approval, a
managed care organization’s approval shall expire 3 years after initial
approval.
(b) Upon each subsequent review and
re-approval, a managed care organization’s approval shall expire 5 years
after re-approval.
(c)
A managed care organization that seeks re-approval shall submit a
full filing, as required by Lab 703.02, 6 months prior to the expiration of its
approval.
Source.. #9217, eff 8-1-08; ss by #12013, eff 10-25-16
PART
Lab 704 RIGHTS AND RESPONSIBILITIES OF
THE PARTIES UNDER MANAGED CARE
Lab 704.01 Employers.
(a)
An employer selecting the managed care option to fulfill its obligations
under RSA 281-A:23 shall:
(1) Inform all employees that it is participating
in a managed care program;
(2) Provide each employee with necessary
information in writing on how to access the network when he or she suffers a
work related injury or illness;
(3)
For all non-first aid claims, as defined in Lab 502.10, notify the insurer,
third party administrator, managed care organization, and department of labor
of all injuries to employees; and
(4) Cooperate with the insurer and managed care
organization in providing temporary alternative duty programs and reinstatement
of injured employees in accordance with Lab 504.04 and 504.05.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 704.02 Managed Care Organization.
(a) Any person or organization
providing managed care services for workers' compensation injuries shall:
(1) Provide the employer with information for
distribution to its employees on how to access the network;
(2) Promptly respond to all employee inquiries on
how and where to obtain treatment within the network; and
(3)
Assign an injury management facilitator to the injured employee's case and
advise the injured employee or the employee's representative of the name of the
facilitator and the method to be used to contact the facilitator for
assistance.
(b)
The injury management facilitator shall:
(1) Act as the case manager for the injured
employee;
(2) Upon request furnish a complete list of the
healthcare providers in the network from which the employee may choose a health
care professional;
(3) Upon request of the injured employee, furnish
a copy of the protocols established by the managed care organization;
(4) Coordinate among the injured employee, health
care professionals and insurer to provide the employee with timely, effective
and appropriate health care services in order to achieve maximum medical
improvement and an expeditious return to work; and
(5) Advise the injured employee of the conditions
under which the injured employee may treat outside the network.
(c)
Neither a managed care organization nor an injury management facilitator
shall perform the duties or functions of an insurance adjuster including, but
not limited to determining the causal relation between the injury and
employment, and determining entitlement to indemnity or impairment benefits.
(d)
Nothing contained in (c) above shall be used to prohibit the managed
care organization or injury management facilitator from obtaining any
information necessary to the management of the injured employee's treatment and
progress to return to work, nor shall any provision in (c) above be construed
to relieve any party of the requirements of Lab 503.01 relating to disclosure.
(e)
A managed care organization shall file with the commissioner:
(1) A report every 6 months indicating whether there were any additions or deletions of
employers for whom the organization is rendering managed care services, and if
so, what those changes were;
(2) A report every 6 months indicating whether
there were any additions or deletions to its health care provider network, and
if so, what those changes were; and
(3) A report whenever there is a substantial
change in the managed care organization or health care provider network
originally approved by the commissioner, or if there is a loss of a necessary
component identified in Lab 703.01.
(f)
A managed care organization shall be subject to monitoring by the
commissioner under RSA 281-A:23-a,VI(a), for purposes of determining the
program’s continued compliance with the standards for approval and delivery of
service.
(g)
A managed care organization whose approval is terminated for any reason
shall notify all its client employers by mail within one week of such
termination and shall send a copy to the department of labor.
(h)
The notice shall include the following words in a conspicuous location:
“The
required New Hampshire approval for this managed care organization has been
terminated. Therefore, you should inform
your employees that an injured worker is no longer required to get treatment
only within the network for workers’ compensation injuries. Instead, the injured worker shall have the
right to select his or her own healthcare provider.”
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08; amd by #10038, eff 12-1-11; ss by #12013, eff 10-25-16
Lab 704.03 Employees.
(a)
For purposes of Lab 704.03, concerning the injured employee’s obligation
to accept treatment within the network and right to treatment outside the
network, ”network” means only those healthcare providers listed in Lab
703.01(d) and Lab703.01(f), as originally approved by the commissioner and
ratified by the advisory council or as changed through reports submitted under
Lab704.02(e).
(b)
An employee who receives medical, hospital or remedial care under a
workers' compensation managed care program shall:
(1) Have the right to choose a physician or other
health care provider from the network, and to make one change of physician or
health care provider within the network at each level of treatment;
(2) Have the right to privacy during examinations
conducted by a health care provider;
(3)
Have the right to obtain a copy of the protocols established by the managed
care organization;
(4) Have the right to treatment outside the
network in accordance with the provisions of Lab 703.01(g);
(5) Have the right to request a second opinion
relative to diagnosis or course of treatment in accordance with Lab 703.01(o);
(6) Have the right to request an independent
medical opinion in accordance with Lab 705.01;
(7) Have the right to subsequent independent
medical opinions, as provided in RSA 281-A:38-a;
(8) Have the obligation to accept treatment
within the healthcare provider network, if the services are provided therein as
described in Lab 703.01(d) and (f); and
(9) Have the obligation to cooperate with the
managed care organization, insurer and employer with respect to temporary
alternative duty assignments and reinstatement to employment as provided in Lab
504.04 and Lab 504.05.
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 704.04 Carriers, Self-Insurers and their
Representatives.
(a)
The carrier or self-insurer providing benefits under RSA 281-A shall
have the responsibility to:
(1) Determine the causal relationship between the
injury and the employee's employment;
(2) Review and authorize or deny payment of all
related medical expenses within 30 days of its receipt of the billing;
(3) Issue any
denials for treatment or benefits presented as associated with the employee's
injuries;
(4) Request and schedule any independent medical examinations
in accordance with Lab 506.01(g);
(5) Pay for an independent medical examination
allowed to the injured employee under the provisions or RSA 281-A:38-a, and Lab
705.03; and
(6) Pay only for charges for care rendered by the
health care providers within the network approved by the commissioner, except
for treatment outside the network specifically authorized or directed by RSA
281-A:23-a, I(b), or by these rules.
(b)
Any carrier, or self-insured employer or employer group, or third party
administrator that provided or paid or gave direction and
guidance to injury management facilitators who worked with their injured
workers prior to July 1, 2011, may continue to operate in that manner. Such injury management facilitators shall be
certified in accordance with Lab 703.01(n).
Source.. #5788, eff 2-17-94, EXPIRED: 2-17-00
New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00
New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08; amd by #10038, eff 12-1-11; ss by #12013, eff 10-25-16
PART
Lab 705 PROCEDURE TO REQUEST AN
INDEPENDENT MEDICAL EXAMINATION
Lab 705.01 First Request to be Granted. If an injured employee who is covered by a
managed care program is dissatisfied with a determination made by the program
relating to compensability, degree of disability or degree of impairment
arising from an injury, the injured employee may apply to the commissioner for
authorization to obtain an independent examination and report thereof by a
health care provider of the injured employee's choice. The commissioner shall grant one such
authorization as a matter of course.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 705.02 Subsequent Requests. Authorization for additional independent
examination regarding the same injury shall be granted only if the commissioner
finds that circumstances exist which cast reasonable doubt on the accuracy of
the report of the first independent examination based upon the circumstances of
the particular case and any written material which contradicts the first
independent exam or the circumstances surrounding that exam.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
Lab 705.03 Payment for Provider's Services. The health care provider conducting an independent
examination authorized by the commissioner in Lab 705.01 shall be paid by the
employer or the employer's insurance carrier.
Nothing in this section shall be construed to prevent an injured
employee from obtaining an examination by a health care provider of the injured
employee's choice at the employee's expense.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08;
ss by #12013, eff 10-25-16
PART
Lab 706 rESERVED
Lab 706.01 Reserved.
Source.. #7338, eff 8-2-00; ss by #9217, eff 8-1-08; rpld by #12013, eff 10-25-16
Appendix
|
Rule |
|
|
|
|
|
Lab
701 |
RSA
281-A:23-a |
|
Lab
702 |
RSA
281-A:23-a |
|
Lab
703 |
RSA
281-A:38-a |
|
Lab
704 |
RSA
281-A:23-a |
|
Lab
705 |
RSA
281-A:38-a |