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Work comp: Medical benefits -- certified managed care plans

A certified managed care (CMO) plan is an organization that has been certified by the state to provide for the delivery and management of medical treatment for injured employees through a network of health care providers. An employer must tell an employee if it is covered by a certified managed care plan.

Current certified plans

The plans currently certified under Minnesota Rules 5218.0100 to provide managed care for workers' compensation claims are the following.

CorVel

Contact:  Employee Intake Nurse, 3001 N.E. Broadway Street, Suite 600, Minneapolis, MN  55413

Phone:  612-436-2403 or 800-275-8893; fax:  612-436-2499

HealthPartners

Contact:  Worksite Health, 8170 33rd Ave. S., Mailstop 21111W, 6 South, P.O. Box 1309, Minneapolis, MN  55440-1309

Phone:  952-883-5396 or 888-779-3625; fax:  952-853-8732

Certified managed care plan coverage

If you are covered by a workers' compensation certified managed care plan here's what you can expect.

  • Your employer must notify each employee of enrollment and tell an employee about managed care coverage when the employee gives notice of a work injury. The employer must also provide the name and phone number of a contact person. The notice requirements are outlined in Minnesota Rules Part 5218.0250, items A to E.

  • You may ask the employer, the insurer or the certified managed care plan staff for a list of providers in the plan.

  • A medical case manager might be assigned to coordinate the delivery of health care for your 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.

  • Final decisions regarding compensability of treatment are still the responsibility of the claim adjuster. These decisions should be based upon the information obtained by providers and case managers of the managed care plan, but the final payment determination is the claim adjuster's.

You must go to a provider in the certified managed care plan unless any of the following are true.

  • You receive approval from either the claims adjuster or the managed care plan to treat with a provider outside the plan.

  • You need emergency medical care.

  • You want to receive care from another health care provider that is able to treat your injury and has treated you at least twice in the past two years or that has a documented history of treating you.

  • You live or work too far from a health care provider in the plan. (There is a 30-mile limit in the seven-county Twin Cities area and a 50-mile limit in all other areas.)

  • Your employer did not give you notice of coverage or the managed care plan is not certified.

  • You were injured prior to the employer's selection of a managed care plan, unless the employee requests to change physicians or is referred by the primary physician for additional care.

  • An employer or insurer took part in the process of forming, owning or operating the managed care plan.

The focus of workers’ compensation certified managed care plans is to:

  • provide prompt evaluation and treatment;

  • encourage communication among employees, providers, qualified rehabilitation consultants (QRCs), employers and insurers;

  • educate health care providers about workers' compensation return-to-work issues;

  • provide medical care management to facilitate appropriate medical care and the employee's return to work; and

  • provide a dispute-resolution process for resolving disagreements between any of the parties about medical issues.

Resolving disputes under a certified managed care plan

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.

Network requirements

A network of health care providers must include:

  • medical doctors, including the following specialties --

    • a specialist in at least one of the following fields:  family medicine, internal medicine, occupational medicine or emergency medicine, and orthopedic surgeons that include a specialist of hand and upper extremity surgery,

    • neurologists and neurosurgeons, and

    • general surgeons;

  • chiropractors;

  • podiatrists;

  • osteopaths;

  • physical and occupational therapists;

  • psychologists or psychiatrists;

  • diagnostic pathology and laboratory services;

  • radiology services; and

  • hospital, outpatient surgery and urgent care services.

More information

For more information about certified managed care, contact the Minnesota Department of Labor and Industry at 651-284-5032 or 800-342-5354.

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