EMPLOYERS Kentucky Managed Health Care Plan (EMP KY MHCP) Guide

Transcription

1 EMPLOYERS Kentucky Managed (EMP KY MHCP) Guide

2 Introduction As your workers compensation insurance carrier, Employers Compensation Insurance Company, Employers Preferred Insurance Company or Employers Assurance Company (EMPLOYERS), we are committed to the well-being and safety of your employees. As part of our commitment, we want to ensure that every employee who sustains a work-related injury or illness obtains prompt medical care, receives high quality treatments, and returns to work as soon as medically possible. We have selected to work with Coventry Health Care Workers Compensation Services, Inc. (Coventry) to offer a Workers Compensation Managed Health Care Plan (MHCP) to your work-related injured or ill employees. The MHCP program offered by Coventry in conjunction with EMPLOYERS is known as the EMPLOYERS KY Managed (EMP KY MHCP). This guide will outline the appropriate use of documents for our policyholders before, during and after the implementation of the EMP KY MHCP. Upon receipt of these materials, please review carefully. Below are documents to make note of during your review process: The KY Workers Compensation Notice is the standard form that needs to be posted at each employer location. Emergency Work-site Posters Worksite posters cannot be used in KY because the employee may choose any provider from within the EMP KY MHCP; however, we believe it a benefit to list the closest hospital or Urgent Care Center at each location to assist in getting the injured employee to the nearest facility in an emergency or at the time of injury. Employers should choose which hospital or Urgent Care Center is closest and fill in this information on the Poster. Our preference would be to use a Network Hospital for this form if closest; however, that is not required. The injured employee should be sent to the nearest facility regardless of network participation. This document should also be posted at each employer location. List of EMP KY MHCO Documents 1. Employer Materials a. KY Workers Compensation Posting Notice b. EMP KY MHCP Hospital Emergency Worksite Poster c. EMP KY MHCP Initial Letter to Employees and Acknowledgement Form d. EMP KY MHCP Channeling Letter

3 2. Employee Materials (Provided by the claims adjuster) a. EMP KY MHCP Employee s Notice b. EMP KY MHCP Verification of Coverage c. EMP KY MHCP Designated Physician Form 113 d. EMP KY MHCP Initial Visit Provider Letter e. EMP KY MHCP Medical Waiver Form 106 f. EMP KY MHCP Grievance Form Review of Materials Upon receipt of these materials, please review carefully. It is imperative that you are fully prepared for this program, what needs to be posted and when to distribute the materials. Here are a few key notes: To Be Posted At Each Employer Location Each Employer should review all the documents being sent to them. Prior to posting, the employer should locate the closest hospital to their location and put this on the Emergency Worksite Poster. The employer should post the following at each location: State of KY Workers Compensation Posting Notice Emergency Hospital Worksite Poster, Sample Copy of the Employee Notice, Initial Visit Provider Letter, and Grievance Form. At Implementation Employers should send the Initial Employee Letter and Acknowledgement Form to each employee. After implementation, these documents should be given to any new hires. The documents can be sent in any format (e.g. presentation, , etc.) Each employee must sign the Acknowledgement form and return it to a key individual at the employer s location. This form should be placed in the employee s personnel file, acknowledging receipt of the information packet. At Notice of Injury If an emergency, send the injured employee to the nearest hospital or urgent care facility for emergency services and then report the claim. For non-emergencies, report the claim first. Initiate the claim process. For your convenience, EMPLOYERS offers several ways to report a claim:

4 - EMPLOYERS Injured Employee Hotline: this hotline is available 24 hours a day, seven days a week and is staffed by registered nurses specially trained to provide medical guidance over the phone for a new work-related illness or injury. Employees or their supervisors can access the hotline by calling Telephone: Claims can be reported 24 hours a day, seven days a week by calling EMPLOYERS Customer Support at Please be prepared to provide your company s policy number, a summary of the injury or illness, and the employee s name and contact information. - send your completed First Report of Injury (FROI) form to ecfroi@employers.com. - Fax: send your completed FROI form to Online at EMPLOYERS.com: o Step 1: Select the For Small Business tab o Step 2: From the menu on the left-hand side, click How to Report a Claim o Step 3: Scroll down to Online and click on Start A Claim (First Report of Injury) Provide the injured employee with the Channeling Letter, which will assist the injured employee in locating a physician. Plan for the employee s return to work with modified light or alternative duty opportunities. Claims adjuster Responsibilities The claims adjuster will supply all other documents after acceptance of the claim. These documents include: the Employee Notice materials that contain a letter to the employee; Verification of Coverage card; Designated Physician Form 113; Initial Visit Provider Letter, Medical Waiver Form 106; and Grievance Form. At some point during the course of care with the injured employee, the claims adjuster may initiate Utilization Review. This is to ensure the services rendered to the injured employee are consistent with Nationally Acceptable Practices guidelines and are medically necessary. The claims adjuster must also initiate Utilization Review with Coventry for the following services: 1. All inpatient stays (Prospective Review) 2. All surgeries (Prospective Review) 3. When a claim reaches $3000 in total medical costs (Retrospective Review) 4. When the lost-time reaches greater than 30 days (Retrospective Review) The claims adjuster may also initiate Case Management with Coventry. Choosing a Gatekeeper

5 When the injured employee requires ongoing treatment beyond the initial treatment, the injured employee must designate a Gatekeeper Physician (a.k.a. Designated Physician) to coordinate care for the injury/illness. The claims adjuster has a list of providers that qualify as Gatekeeper Physicians and can assist the injured employee if necessary. A Gatekeeper Card will be sent with the other materials at the time of injury from the claims adjuster to the injured employee. Ask the Claims adjuster Whenever there are questions on a claim, contact the claims adjuster for information. Here are some activities where the injured employee may need additional claims adjuster support: Coordination of Care When a provider terminates, it is the provider s responsibility to notify the injured employee that they are no longer part of the network. The injured employee may request the claims adjuster confirm the provider has terminated. If the terminated provider is a Gatekeeper, the injured employee must choose a new Gatekeeper. Change of Provider Any provider changes must be approved/denied by the claims adjuster. The injured employee may make a one-time change of provider within the network without approval upon completion of a second Designated Physician Form 113 (provided by the claims adjuster). Exceptions for Using Non-Network Providers/Facilities: (Out of Network Requests) The injured employee should use a network provider whenever possible. The claims adjuster may authorize access to a non-network provider for the following circumstances: For emergency care. When the Gatekeeper Physician refers an employee outside the managed care plan for medical services. When authorized treatment is unavailable through the managed care plan; To obtain a second opinion when a managed care plan physician recommends surgery. For those injuries or diseases for which continuing treatment was initiated prior to the date the managed care plan for the employer was approved, the employee may continue with its current treating physician. If initial emergency care following a compensable injury is rendered by a medical provider outside the managed health care plan, the injured employee may remain under the care of that provider so long as the provider complies with utilization review, reporting standards, and quality assurance mechanisms prescribed by the employer s managed care plan.