A.
MANAGED
CARE ORGANIZATION APPLICATION FOR CERTIFICATION
1. MCO Certification
a. Any person or entity may make written
application to the Administrator for certification as an MCO.
b. Two (2) copies of the application must be
submitted. The application must include the following specific information to
ensure the MCO will be able to meet the provisions of this rule:
(1) The names of all directors and officers
of the organization and the name, address, and telephone number of a
communication liaison for the proposed plan.
(2) The names, addresses, and specialties of
the individuals who will provide services under the MCO.
(3) A statement describing how the plan will
ensure an adequate number of health care providers to give employees convenient
accessibility to all categories of providers.
(4) The rules, terms, and conditions
regarding the services the MCO will be providing.
(5) All entities, with whom the MCO has an
agreement to perform any of the functions of the managed care plan, and a
description of the specific functions to be performed by each such entity. A
sample contract which complies with Rule
33 page 8 c and d must be
furnished.
(6) A copy of the
organizational documents of the applicant, such as the articles of
incorporation, articles of association, partnership agreement, trust agreement,
or other applicable documents, as well as the by-laws or similar document, if
any.
(7) A description of the MCO's
Quality Assurance Program which shall include, but is not limited to:
(a) An internal dispute resolution
program.
(b) A medical peer review
program.
(c) Pre-admission review
program which complies with Rule
30.
(d) Second surgical opinion
program.
(e) Utilization Review
Program which includes concurrent and retrospective review. The MCO utilization
review program must meet the requirements of Ark. Code Ann. §§
20-9-902,
et seq. (1989), the Rules & Regulations for Utilization Review in
Arkansas, and must be certified with the Arkansas Department of Health
Utilization Review Certification Program as a Private Review Agent.
(f) Technical and professional review
programs which shall comply with Rule
30, and satisfy
the requirements of Ark. Code Ann. §§
20-9-902,
et seq. (1989).
c. The MCO must provide programs through
which participating health care providers may obtain information on the
following topics:
(1) treatment parameters
adopted by the Commission;
(2) end
of healing period;
(3) permanent
partial impairment rating;
(4)
return to work and disability management;
(5) health care provider obligation in the
workers' compensation system; and
(6) other topics the MCO or Commission deems
necessary to obtain cost effective medical treatment and appropriate return to
work for an injured employee.
The medical director of an MCO must document attendance for a
minimum of six (6) hours of education during the first year, and three (3)
hours each year thereafter, covering any of the topics listed in items (1) to
(6) above. The documentation shall be submitted to the Administrator upon
request. The medical director or designee must be available as a consultant on
these topics to any health care provider delivering services under the
MCO.
d. The MCO
must describe its program far medical case management which must at a minimum
comply with the following rule requirements:
(1) A description of how medical case
management will be provided.
(2)
Retention of Medical Case Manager.
A medical case manager shall monitor, evaluate, and coordinate
the delivery of quality, cost effective medical treatment and other health care
services needed by an injured employee. Medical case managers should ensure
that the injured or disabled employee is following the prescribed medical care
plan, and shall promote an appropriate, prompt return to work. Medical case
managers shall facilitate communication between the employee, employer,
insurance carrier/self-insured, health care provider, managed care plan, and
any assigned vocational rehabilitation counselor to achieve these goals.
(3) Qualifications of medical case
manager.
A medical case manager for the purposes of this Rule means an
individual who provides or supervises the provision of medical case management
services under the MCO and who is either:
(a) a physician licensed in Arkansas;
or
(b) a Designated Certified Case
Manager (CCM) by the Certification of Insurance Rehabilitation Specialists
Commission for Case Manager Certification; or,
(c) currently licensed as a Registered Nurse
(RN); or,
(d) currently licensed
as an Occupational Health Nurse; or,
(e) currently licensed as a Licensed
Practical Nurse (LPN) and have 18 months supervised clinical experience and 6
months acceptable case management experience.
e. Each application for original
certification, or application for certification following revocation, must be
accompanied by a non-refundable fee of $500.
f. An application received by the Commission
shall be approved within forty-five (45) days of receipt of all required
information if such application meets all certification requirements. Further
information or clarification of submitted information may be requested from the
applicant. Failure to respond to a request from the Commission or failure to
meet the requirements shall result in a denial of certification. A letter
detailing the reason(s) for denial shall be sent to the applicant within five
(5) working days of the decision by the Commission to deny the
application.
g. An applicant denied
certification shall be permitted to reapply no earlier than thirty (3 0) days
after receipt of the notice of denial of certification. Such application shall
be accompanied by a non-refundable fee of $250. In no event shall an entity be
allowed to reapply for one (1) year after having been denied certification
three (3) consecutive times.
h.
MCOs shall be initially certified for two years and must undergo certification
review every two years thereafter.
2. Contracts.
a. In order to provide management of
treatment for injuries and diseases compensable under the Arkansas Workers'
Compensation Act, an MCO may contract with:
(1) An insurance carrier licensed by the
Arkansas Department of Insurance to write workers' compensation insurance in
this state that has provided the Commission with a current A-13, or
(2) An individual employer or group of
employers approved for self-insurance by the Commission.
b. An MCO shall provide comprehensive medical
services in accordance with its certification to all injured workers covered by
the insurance carrier/self-insured contracts.
c. Copies of all contract agreement(s) shall
be made available upon request from the Arkansas Workers' Compensation
Commission.
d. When a MCO contracts
with an insurance carrier /self -insured employer to provide services, the
contract shall specify those employers governed by the contract. The MCO
contract must include the following terms and conditions when establishing who
is governed by the contract:
(1) Insurance
carriers/self-insured employers may contract with more than one MCO to provide
services for employers, however, all workers at any specific employer's
location with accepted compensable injuries shall be governed by the same
MCO(s).
(2) To ensure continuity of
care, the MCO contract shall specify the manner in which injured workers with
compensable injuries will receive medical services when an MCO contract
terminates. When MCO coverage for an injured worker is transferred from one MCO
to another, the worker may continue to treat with his/her attending physician
until a change of physician occurs.
e. Notwithstanding the requirements of this
rule, failure of the MCO to provide such medical services does not relieve the
insurance carriers/ self-insured employers of their responsibility to ensure
that medical benefits are provided to injured workers.
B.
INTERNAL MANAGED CARE
SYSTEM'S APPLICATION FOR CERTIFICATION
1. Any insurance carrier, employer,
individual self-insured employer, or group self-insured employer may make
application to the Administrator for certification of its in-house managed care
system.
2. The application must
include the following specific information to ensure the IMCS will be able to
meet the provisions of this rule:
a. The name,
address, and telephone number of a communication liaison for the
IMCS.
b. A "description of the
IMCS. The description of the IMCS must include the rules, terms, and conditions
regarding the services the IMCS will be providing.
c. A list of the names, addresses, and
specialties of the individuals who will provide services for the
IMCS.
d. The name(s) and
qualifications of those individuals who will be providing case management
services for the IMCS.
e. The
description of a program for medical case management which shall not be limited
to but which must at a minimum comply with Part
II. A. 1. d. of this rule. See
page 5.
f. The description of a
program for quality assurance which shall not be limited to but which must at a
minimum comply with Part
II. A. 1. b. (7) of this rule.
See page 4.
3. Each
request for certification of an IMCS must be accompanied by a non-refundable
application fee of $500.00.
4.
Approval of certification is dependent upon proof of compliance with the
above.
5. An approved IMCS may
provide services only to their policyholders, employees, and/or group
self-insured employers.
C.
REPORTING REQUIREMENTS
1. MCO Reporting Requirements.
a. In order to maintain certification, each
MCO shall provide within thirty (30} days following each anniversary of
certification the following information for the previous calendar year:
(1) a current membership listing by category
of medical service providers, including provider names as required in Part
II. B. of this rule;
and
(2) A listing of all employers
covered by each contract.
(3) a
summary of any sanctions or punitive actions taken by the MCO against
participating health care providers;
(4) a summary of actions taken by the MCO's
peer review committee which shows the number of cases reviewed, issues
involved, and action taken;
(5) a
list of entities other than health care providers that perform any of the
functions of the MCO plan, which were not previously provided with the
application for certification.
(6)
any other information requested by the Commission which is deemed
reasonable/necessary to monitor the MCO's compliance with the requirements of
this rule.
b. The MCO
must report to the insurance carrier/self-insured employer, and Arkansas
Workers' Compensation Commission any data regarding medical, surgical, and
hospital services related to a workers' compensation claim requested by the
insurance carrier, self-insured employer, or Arkansas Workers' Compensation
Commission.
2.I MCS Reporting Requirements
I n order to maintain
certification, each IMCS shall provide within thirty (30) days following each
anniversary of certification the following information:
a. a summary of any sanctions or punitive
actions taken by the IMCS against participating providers ,-
b. a summary of actions taken by the IMCS' s
peer review committee which shows the number of cases reviewed, issues
involved, and action taken;
c. any
other information requested by the Commission which is deemed
reasonable/necessary to monitor the IMCS's compliance with the requirements of
this rule.
d. any significant
changes in the certified plan or provider network.
D.
RECORD MAINTENANCE
1. Every MCO/IMCS that is certified to
provide medical services as required by this rule shall maintain records for
three (3) full calendar years.
2 .
If the insurance carrier's/self-insured employer's contract with the MCO is
canceled for any reason, all MCO records relating to treatment provided to
workers within the MCO must be forwarded to the insurance carrier/self-insured
employer upon request.
3.
Individual MCO/IMCS participating providers must maintain claimant medical
records. The records must be legible and cannot be kept in a coded or
semi-coded manner unless a legend is provided within each set of records. The
records shall contain:
a. objective and
subjective findings; and
b.
complete case history of the services rendered (diagnostic and therapeutic
procedures employed) to each claimant, and the time involved if the procedure
being billed is based upon time.
E.
DISPUTE RESOLUTION
1. MCO/IMCS Internal Dispute Resolution
Program
Disputes, other than choice and change of physician, which arise
on an issue related to managed care, such as the question of inappropriate,
excessive, or not medically necessary treatment, medical disputes, disputes
regarding non-participating providers, etc., between the employee, health care
provider, managed care plan, insurance carrier/self-insured employer, or
employer shall first be processed without charge to the employee or health care
provider through the dispute resolution process of the MCO/IMCS. Disputes must
be in writing and filed within thirty (30) days of the dispute. The MCO/IMCS
dispute resolution process must be completed within thirty (30) days of receipt
of a written request. If the dispute cannot be resolved, or one of the parties
so requests in writing, the Administrator shall assist in resolution pursuant
to the administrative review process as set out below. For change of physician
see Part I, D (page 3) of this rule. For choice of physician see Part I, B
(page 2} of this rule.
2.
Administrative Review.
The process for administrative review of such matters shall be as
follows:
a. The request for
administrative review shall be made in writing to the Administrator within
ninety (90) days of the disputed action. No administrative review shall be
granted unless the request is in writing and specifies the grounds upon which
the action is contested and is received by the Administrator within ninety (90)
days of the contested action, unless the Administrator or his/her designee
determines that there was good cause for delay or that substantial injustice
may otherwise result.
b. When the
request for administrative review is received by the Administrator and it is
determined that the Commission has jurisdiction over the cause of action, all
parties shall be notified by certified mail return receipt requested. All
parties shall have thirty (30) days from the date of receipt of notification to
submit further evidence, documentation, or clarification to the
Administrator.
c. The review may be
conducted by the Administrator or the Administrator's designee. The review may
include a hearing where all parties to the dispute will be required to attend
All hearings will be recorded. Failure to appear at such hearing may result in
dismissal of the request for administrative review.
d. An order or award shall be issued within
thirty (30) days.
e. Any party
feeling aggrieved by the order of the Administrator shall have ten (10) days
from the date of the notification to request a rehearing. A request for
rehearing shall be in writing and shall state the grounds upon which the moving
party relies. Upon a finding that the record is not complete or that error was
made in the hearing process, the Administrator may order a rehearing. A
rehearing shall follow the same procedure as the initial administrative
review.
f. Any party feeling
aggrieved by the rehearing order of the Administrator shall have ten (10) days
from the date of the notification to appeal the ruling to an Administrative Law
Judge of the Arkansas Workers' Compensation Commission. The notice of appeal
shall be filed with the Clerk of the Commission. The notice of appeal shall
contain the following:
(1) a copy of the
Administrative Review Order appealed; and
(2) copies of all materials submitted to the
Administrator in the administrative review proceedings; and
(3) a statement identifying each portion of
the Administrator's order claimed to be in error; and
(4) an explanation of how each portion of the
Administrator's order conflicts with Rule
33.
The appealing party shall mail a copy of all materials which are
filed in the appeal to each opposing party. No response to the appeal of the
Administrator's order is required. A decision must be entered by the
Administrator or Administrator's designee before any appeal may be
brought.
An order or award of an Administrative Law Judge shall become
final unless a party to the dispute shall, within thirty (30) days from the
receipt by him of the order or award, petition in writing for a review by the
Full Commission of the order or award. See Ark. Code Ann. §
11-9-711(a)
(1) (1987).
An order or award of the Commission shall became final unless a
party to the dispute shall, within thirty (30) days from receipt of the order
or award, file notice of appeal to the Court of Appeals. See Ark. Code Ann.
§
11-9-711(b)
(1987).
F.
MONITORING/AUDITING
1. The Commission for good cause may monitor
and conduct periodic audits and special examinations of the MCO/IMCS as
necessary to ensure compliance with the MCO/IMCS certification and performance
requirements and any applicable Rule
30 requirements.
2. All records of the MCO/IMCS and their
individual members shall be disclosed within a reasonable time upon request of
the Commission. These records must be legible and cannot be kept in a coded or
semi-coded manner unless a legend is provided for the codes.
G.
CHARGES AND FEES
1. Billings for medical services under a
MCO/IMCS shall be submitted in the form and format as prescribed in Rule
30. The payment of medical
services may be less than, but shall not exceed, the maximum amounts allowed
pursuant to Rule
30 of the Arkansas Workers'
Compensation Commission.
2. Fees
paid to medical providers who are not subject to the terms of an agreement with
an MCO/IMCS shall be governed by the provisions of Rule
30 of the Arkansas Workers'
Compensation Commission.
3. Balance
billing as defined in Rule
30 by medical providers and/or
facilities is specifically prohibited. The MCO/IMCS must have an effective plan
for handling balance billing.
H.
COMPLAINTS/INVESTIGATION
1. Complaints pertaining to the operations of
a MCO/IMCS shall be directed in writing to the Administrator. Upon receipt of a
written complaint, or after monitoring the MCOs/IMCSs, the Administrator may
investigate the alleged violation. The investigation may include, but shall not
be limited to, requests for and review of pertinent MCO/IMCS records,
interviews with the parties to the complaint, or consultation with an
appropriate committee of the medical provider's peers. If the investigation
reveals a violation, the certification may be suspended or revoked or the IMCS
may be placed on probation. The Administrator may return the complaint to the
originating party for completion if the complaint does not satisfy the
requirements of this rule. The complaint must:
a. state the grounds for alleging a rule
violation;
b. include the specific
contentions of error;
c. state the
complainant's request for correction and relief; and
d. include sufficient documentation to
support the complaint.
2. Upon completion of the investigation, if
the Administrator determines there has been a violation, the Administrator may
issue sanctions and/or penalties pursuant to Part
II,
I of this rule.
I.
SUSPENSION/REVOCATION1. The
certification of an MCO/IMCS may be suspended, placed on probation or revoked
by the Administrator if:
a. the MCO/IMCS Plan
for providing services fails to meet the requirements of this rule;
b. service under the plan is not being
provided in accordance with the terms of the certified plan;
c. any false or misleading information is
submitted by the MCO/IMCS or any participating providers of the
organization;
d. the MCO/IMCS
continues to use the services of a health care provider whose license,
registration, or certification has been suspended or revoked; or
e. there is "a change in legal entity of the
MCO/IMCS which does not conform to the requirements of this rule;
2. For the purpose of this rule:
a. "Suspension" means an MCO may not enter
into new contracts with insurance carrier/self-insured employers for a
specified period of time. The suspension period may be imposed for a period up
to a maximum of one year.
b.
"Probation" means that an IMCS has been given a specified length of time in
which to remedy any problem(s) of which it has been notified pursuant to Part
II, H of this rule.
c. "Revocation" means a permanent revocation
of a MCO/IMCS's certification to provide services under this rule.
d. "Show Cause Hearing" means an informal
hearing with the Administrator or his/her designee at which the MCO/IMCS may be
heard and present evidence regarding the Administrator's intent to suspend,
place on probation, or revoke the MCO/lMCS's certification.
3. A show cause hearing may be
held at any time the Administrator has reason to believe a MCO/IMCS has failed
to comply with its obligations under the Arkansas Workers' Compensation Act,
Commission Rules, or orders of the Administrator, or when serious questions of
operation of and MCO/IMCS warrant a hearing.
4. Suspension, probation, or revocation under
this rule will not be made until the MCO/IMCS has been given notice and the
opportunity to be heard at a hearing before the Administrator to show cause why
it should be permitted to continue to provide services under this
rule.
5. The process for
suspension/probation/revocation shall be as follows:
a. The Administrator shall provide the
MCO/IMCS written notice of an intent to suspend, place on probation, or revoke
the MCO/IMCS's certification and the grounds for such action. The notice shall
also advise the MCO/IMCS of its right to participate in a show cause hearing
and the date, time and place of the hearing. The notice shall be sent by
certified mail at least thirty (30) days prior to the scheduled date of the
hearing.
b. After the show cause
hearing, the Administrator may issue an order suspending, placing on probation,
or revoking the MCO/IMCS.
c. Upon
suspension or probation the MCO/IMCS may continue to provide services in
accordance with the contracts in effect at the time of the
suspension/probation. Prior to the end of the suspension/probation period the
Administrator shall determine if the MCO/IMCS is in compliance. If the MCO/IMCS
is in compliance, the suspension/probation will terminate on its designated
date. If the MCO/IMCS is not in compliance, the suspension/probation may be
extended without further hearing or revocation proceedings may be initiated. A
suspension/probation may be set aside prior to the designated end of the
suspension/probation period if the Administrator is satisfied that the MCO/IMCS
is in compliance with Rule
33.
d. If the MCO/IMCS certificate is suspended,
placed on probation or revoked the Administrator shall allow for a rehearing
and shall give the MCO/IMCS at least ten {10} days notice of the time and place
of the rehearing. Within thirty (30) days after the hearing, the Administrator
shall either affirm or withdraw the revocation and give the MCO/IMCS written
notice thereof by registered or certified mail. If revocation is affirmed after
rehearing by the Administrator, the revocation is effective ten (10) days after
the MCO/IMCS receives notice of the affirmance, unless the MCO/IMCS appeals to
an Administrative Law Judge.
e. If
the revocation is affirmed following judicial review by an Administrative Law
Judge, the revocation is effective ten (10) days after entry of the final
decree of affirmance.
7.
After revocation of a MCO/IMCS's authority to provide services under these
rules has been in effect for one (1) year or longer, it may petition the
Administrator to restore its authority by submitting a plan and application in
the form and format as required by Part
II, C. & D. of this
rule.
8. Insurance
carrier/self-insured employer contractual obligations to allow a MCO to provide
medical services for injured workers shall be null and void upon revocation of
the MCO/IMCS certification by the Administrator.
9. Any contractual obligations of a health
care provider or other entity to deliver medical, surgical, or hospital
services pursuant to the Arkansas Workers' Compensation Act or to comply with
any rules, terms, and conditions of the MCO/IMCS or to make referrals into the
MCO/IMCS shall be null and void upon revocation of the certification of the
MCO/IMCS.
J.
SERVICE OF ORDERS
1. When the
Administrator suspends/places on probation or revokes certification of an
MCO/IMCS or assesses a penalty, the order, including a notice of the party's
appeal rights, shall be served upon the party.
2. The order shall be served by delivering a
copy to the party through certified mail return receipt requested or in any
manner provided by the Arkansas Rules of Civil Procedure.
K.
AMENDMENTS / CHANGES
Any amendments and/or changes to the certified MCO/IMCS plan must
be approved by the Administrator before becoming effective.
L.
APPLICABILITY OF RULES
1. This revised rule shall be adopted January
1, 1997 and shall govern all Arkansas Workers' Compensation managed care
organizations and/or internal managed care systems.
2. The provisions of these rules shall be
applicable to all such managed care organizations and/or internal managed care
systems and services rendered thereby, subsequent to the effective' date of
this rule.
