Minnesota Administrative Rules

5221.0430 CHANGE OF HEALTH CARE PROVIDER.

Subpart 1.

Primary health care provider.

The individual health care provider directing and coordinating medical care to the employee following the injury is the primary health care provider. If the employee receives medical care after the injury from a provider on two occasions, the provider is considered the primary health care provider if that individual directs and coordinates the course of medical care provided to the employee. The employee may have only one primary health care provider at a time. The selection of a provider by an employee covered by a certified managed care plan is governed by chapter 5218.

Subp. 2.

Change of health care provider.

Following selection of a primary provider, the employee may change primary providers once within the first 60 days after initiation of medical treatment for the injury without the need for approval from the insurer, the department, or a workers' compensation judge. After the first 60 days following initiation of medical treatment for the injury, any further changes of primary provider must be approved by the insurer, the department, or a workers' compensation judge. However, at any time throughout the claim, transfer of medical care coordination due to conditions beyond the employee's control, such as retirement, death, cessation from practice of the primary provider, or a referral from the primary provider to another provider, does not require prior approval. If the employee is covered by a certified managed care plan, a change of providers is governed by chapter 5218, Minnesota Statutes, section 176.1351, subdivision 2, clause (11), and procedures under the plan.

Subp. 3.

Unauthorized change; prohibited payments.

If the employee or health care provider fails to obtain approval of a change of provider before commencing treatment where required by this part, the insurer is not liable for the treatment rendered prior to approval unless the insurer has agreed to pay for the treatment. Treatment rendered before a change of provider is approved under this subpart is not inappropriate if the treatment was provided in an emergency situation and prior approval could not reasonably have been obtained.

Subp. 4.

Change of primary provider not approved.

After the first 60 days following initiation of medical treatment for the injury, or after the employee has exercised the employee's right to change doctors once, the department, a certified managed care organization, or a compensation judge shall not approve a party's request to change primary providers, where:

A.

a significant reason underlying the request is an attempt to block reasonable treatment or to avoid acting on the provider's opinion concerning the employee's ability to return to work;

B.

the change is to develop litigation strategy rather than to pursue appropriate diagnosis and treatment;

C.

the provider lacks the expertise to treat the employee for the injury;

D.

the travel distance to obtain treatment is an unnecessary expense and the same care is available at a more reasonable location;

E.

at the time of the employee's request, no further treatment is needed; or

F.

for another reason, the request is not in the best interest of the employee and the employer.

Statutory Authority:

MS s 175.171; 176.101; 176.135; 176.1351; 176.136; 176.231; 176.83

History:

18 SR 1472; 25 SR 1142

Published Electronically:

June 11, 2008