Minnesota Administrative Rules

5218.0500 HEALTH CARE PROVIDERS WHO ARE NOT PARTICIPATING HEALTH CARE PROVIDERS.

Subpart 1.

Authorized services.

A health care provider who is not a participating health care provider may provide medical services to an employee covered by a managed care plan in any of the circumstances in items A to D. The employer or insurer must notify the managed care plan of treatment under items A, B, and D and the managed care plan, employer, or insurer must initiate the contact with the nonparticipating provider. The managed care plan must explain its requirements and procedures to the nonparticipating health care provider, and must provide the plan's toll-free telephone number through which the nonparticipating provider may obtain information about the plan's requirements and procedures and other information specified in part 5218.0100, subpart 1, item L.

A.

A nonparticipating provider may deliver services to an employee if the treatment is within the provider's scope of practice, if the health care provider maintains the employee's medical records and has a documented history of treatment with the employee before the date of injury, whether for a work-related condition or not, and so long as the provider complies with subpart 2 and Minnesota Statutes, section 176.1351, subdivision 2, clause (8). A documented history of treatment does not include evaluations for no or minimal compensation or treatment of an injury before notice of the injury is given to the employer. The requirement of a history of treatment will be deemed to be satisfied if the employee documents at least two visits with the provider within the two years before the date of the injury. Employees with a history of treatment that does not meet this standard may request approval from the managed care plan or the insurer. If approval is denied, the employee may contest the denial according to the procedures in subpart 3 and part 5218.0700.

The employee must, within ten calendar days of notice to an employer of an injury, provide the managed care plan or insurer with copies of medical records or a letter from the health care provider documenting the dates of the previous treatment. The managed care plan or insurer must treat the medical records as private data. If the employee requests a change of doctor, further services shall be provided by the managed care plan according to part 5218.0100, subpart 1, item F, subitems (2) and (3).

B.

A nonparticipating provider may deliver services to an employee for emergency treatment.

C.

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

D.

A nonparticipating provider may deliver services to an employee when the employee has received treatment for a claimed injury from a nonparticipating provider under part 5218.0200, subpart 5, items B and D, where liability for the injury is admitted or established later than 14 days after the employer received notice of the injury.

Subp. 2.

Requirements.

To deliver services to an employee under subpart 1, items A and D, a health care provider who is not a participating health care provider must:

A.

agree to comply with the managed care plan treatment standards, utilization review, peer review, dispute resolution, and billing and reporting procedures; and

B.

agree to refer the covered employee to the managed care plan for specialized services, including without limitation physical therapy and diagnostic testing, except for minor diagnostic testing that may be done in the nonparticipating provider's office. The nonparticipating provider referring the employee may continue to act as the primary treating provider.

Subp. 3.

Disputes.

Any dispute under subpart 1 or 2 relating to the employee's selection of a health care provider who is not a managed care plan participating health care provider shall be resolved according to part 5218.0700. Any dispute relating to a health care provider's compliance with the managed care plan standards and procedures or treatment standards adopted by the commissioner shall be resolved according to part 5218.0700. A health care provider who has been informed that an injured employee is covered by a managed care plan and who does not comply with the requirements in subpart 2 is subject to denial of payment for the services in accordance with the procedures in part 5218.0700 and sanctions under Minnesota Statutes, section 176.103.

Statutory Authority:

MS s 176.1351

History:

18 SR 1379

Published Electronically:

June 11, 2008