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Workers' compensation -- Certified managed care



Frequently asked questions

1. What is workers' compensation certified managed care?


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Workers' compensation managed care plans are certified by the Minnesota Department of Labor and Industry, and provide for the delivery and management of medical treatment for injured employees through a network of health care providers.

An employee covered by managed care selects a treating doctor from the network, which must include medical doctors, chiropractors, osteopaths, podiatrists, physical and occupational therapists, and specialists. Sometimes the employer and managed care plan designate a clinic for the initial visit after an injury, but an employee may select any doctor in the plan for additional treatment that is needed. In some cases, the employee may be able to continue treating with a doctor outside of the network with whom the employee has established a relationship before the injury.

Certified managed care plan case managers, who are licensed health care professionals, monitor and coordinate the delivery of quality medical treatment, help the parties communicate with each other and the doctor, and promote an appropriate, prompt return to work. The certified managed care plan must also include a process for resolving disputes.

 

2. How do I know if I am covered by a certified managed care plan?


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There are three certified workers' compensation managed care plans. An employer or workers' compensation insurer that has contracted with a certified managed care plan must post a notice, notify each employee of enrollment and tell an employee about managed care coverage when the employee gives notice of a work injury.

There are some workers' compensation managed care plans that are not certified.

An employee is not required to receive treatment for a work injury from a specific network of providers if notice of coverage has not been given or if the managed care plan is not certified.

 

3. What is the process for resolving disputes under a certified managed care plan?


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Workers' compensation certified managed care is expected to reduce the number of disputes that arise in workers' compensation, by encouraging quality treatment, communication between the parties and appropriate return to work. However, if there is a difference of opinion about a medical issue related to managed care, the workers' compensation law requires that each certified managed care plan must try to resolve the dispute.

An employee or health care provider may start this process by submitting a written complaint to the managed care plan; some plans will also accept complaints by telephone. The plan must respond to the employee or health care provider within 30 days after receiving the complaint.

If an employee or health care provider is not satisfied with the response from the managed care plan, or if the managed care plan does not respond to a written complaint within 30 days, the employee or provider may file a Medical Request form with the Department of Labor and Industry.

A copy of the written complaint that was submitted to the managed care plan, or other documentation that the managed care plan's dispute process has been completed, must be attached to the Medical Request form. The managed care plan's response may also be attached, but this is not required.

The requirement that a dispute must be submitted to the managed care plan first applies only if an employee is covered by a certified managed care plan.

 

Ask a question

If you don't see your question answered here or want more information about certified managed care, contact the Minnesota Department of Labor and Industry at (651) 284-5005 or 1-800-342-5354.

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