CONNECTICUT MANAGED HEALTH CARE SYSTEM (MCP) PROVIDER REFERENCE MANUAL

Transcription

1 CONNECTICUT MANAGED HEALTH CARE SYSTEM (MCP) PROVIDER REFERENCE MANUAL (800) (Rev. 7-11)

2 ABOUT COVENTRY Coventry Workers Comp Services is a division of Coventry Health Care, Inc. Coventry serves the occupational health care market by providing employers, insurers and claims payors with a variety of integrated health care services through specialized preferred provider organizations (PPOs) that include hospitals, physicians and ancillary services for workers' compensation injuries. Coventry Integrated Network sm includes providers contracted for workers' compensation who share in our common goal of returning the injured worker to productivity at the earliest opportunity. COVENTRY CONNECTICUT MEDICAL CARE PLAN Under Sec and Connecticut Workers Compensation law, the state offers employers the ability to participate in an organized managed care plan called the Connecticut MCP. The Connect Managed Care Plan (CT MCP) is designed to assist workers compensation insurers in controlling health care costs while maintaining quality medical care. Coventry is an approved "sponsor" for the Connecticut Medical Care Plan (CT MCP). This means that Coventry submitted a plan of operations to the State for approval. Our Sponsoring Organizations includes the following components: The Coventry Integrated Network Coventry's Utilization Review Coventry's Telephonic and Field Case Management services Complaint & Grievance Resolution Ongoing Quality Improvement Reporting Coventry received approval from the State for its Sponsoring Organizations. Carriers, employers, third-party administrators or other entities may choose to use Coventry s CT MCP for their insured and employees. COVENTRY PROVIDER REFERENCE MANUAL All Coventry Network Providers in Connecticut for workers' compensation are part of Coventry's CT MCP. This manual is intended to assist in understanding all the provider responsibilities of the CT MCP. Coventry Integrated Network sm is a service mark of Coventry Workers Comp Services, Inc. (CWCS), a division of Coventry Health 2

3 HOW CLIENTS USE THE CONNECTICUT MCP Clients can access Coventry s services in the following ways: Fully Bundled: Coventry is approved as the Sponsoring Organizations and provides all components of the program, including network access and support, utilization review, case management, quality improvement, complaint and grievance resolution, and reporting. Network Only: Other entities like Carriers, Third-Party Administrators or other managed care entities are approved as their own sponsoring plan and solely use the Coventry Integrated Network. SERVICE AREAS Coventry is certified statewide. NETWORK ACCESS REQUIREMENTS: Network certification is based on access to providers within a 25 mile radius from the employer's location. The Network must include the following: At least one occupational health clinic, auxiliary occupational health clinic or hospital that has a Board Eligible or Board Certified Occupational Health Physician, and At least three providers (not in the same group or practice) or two providers (not in the same group or practice) with a minimum choice in total of five individual providers of each of the following types of specialties: Cardiology Chiropractic Dentistry Dermatology Family Practice Gastroenterology General Hospital General Surgery Internal Medicine Other 1 Neurology Neurological Surgery OB GYN Ophthalmology Optometry Orthopedic Surgery Otolaryngology Physical Med & Reh Physical Therapy Plastic Surgery Podiatry Psychiatry Psychology Pulmonary Medicine Radiology Thoracic Surgery Urology 1 Other includes any medical or health care services the MCP determines to be necessary. Coventry Integrated Network sm is a service mark of Coventry Workers Comp Services, Inc. (CWCS), a division of Coventry Health 3

4 4 GENERAL NETWORK REQUIREMENTS: Insurers participating in Coventry s MCP and/or using The Coventry MCP Network are actively channeling injured workers to your practice. To ensure that all parties achieve maximum benefits through this program, you are required to: Accept the contract rate as payment in full See injured workers who require urgent care within 24 hours of the request. See injured workers for initial non-emergency care within 3 days of the request See referred workers compensation patients as soon as possible Encourage injured workers return to work as soon as medically appropriate Work with Coventry and its clients utilization management programs Report detailed information about the capabilities and limitations of the injured worker to the carrier Comply with requests for verbal and written reports Refer to other network providers when available APPOINTMENTS AND WAITING TIMES MCP regulations indicate that the injured worker should be seen with reasonable promptness. Coventry recommends the following standards: Acceptable waiting time in a provider s office or clinic should not exceed reasonable community standards of more than minutes. Appointment time with the provider should allow for adequate physician/injured worker interaction from minutes. PROVIDER SERVICES (800) Coventry provides access to its Provider Services Department to assist you with any questions about your participation in the Coventry Integrated Network sm. Provider Services can assist with the following: Network participation status Provider reimbursement Payment Status Patient identification Other administrative/program issues COMPENSATION Compensation for services remains within the sole discretion of the workers compensation carrier or TPA; however, Utilization Review requirements (which differ from one MCP to another) may be required by the MCP and may result in non-payment for non-certified, non-emergency services. Please refer to the Coventry UR requirements noted later in this document or go to Coventry s website to contact the payors with any questions regarding non-payment for any services. LOCATING ANOTHER SPECIALTY PROVIDER You may locate a Coventry CWMP provider through this website at Go to Locate a Provider at the top, left of this website. You will only need a zip code and specialty to find a provider. If you need assistance, call the Coventry Provider Services at 1(800) RECORDS Maintaining medical records should be handled in a manner consistent with professional medical record-keeping guidelines. Providers should retain records for injured workers for a minimum of fifteen years. Records should be legible, complete, accurate, and easily retrievable. Additionally, providers should protect the confidentiality of the

5 injured worker. Medical records should include significant procedures, past and current diagnosis, patient demographics (i.e. patient name, employer name, date of birth, etc), original report of injury and complete and accurate history. Additionally, documentation for each visit should include the following: Subsequent progress reports Chief complaint Therapies administered/prescribed Providers signature/initials/ Objective findings of Practitioner Studies Ordered (i.e. labs, x-rays) Diagnosis or Medical Impressions and if work activity contributed substantially/significantly to the cause of the diagnosis Employee s work status and any limitations Referrals to other physicians and basis for referral and/or link to compensable injury or condition Significant clinical developments as treatment evolves Name and profession of practitioner After office visits or other medical developments SAMPLE MEDICAL REPORTING FORM An Employee Medical & Work Status Report Form is attached to maintain the consistency of documentation for all providers. Although all injured workers are instructed to bring a form with them at the time of treatment, there may be occasions when they arrive without one - especially on a follow-up visit. It is very important that providers complete the Medical & Work Status Report form and distribute the forms to all pertinent parties including the Utilization Review entity and payors. In addition to the Employee Medical & Work Status Report Form, physicians are expected to complete forms that have been approved by the Workers Compensation Commission when and if the workers injury demands completion. These forms address the employee s work status or the extent of permanent injury to a body part once a patient reaches maximum medical improvement. These forms include Form 36 title Notice to Employee and Compensation Commissioner of Intention to Discontinue or Reduce Payments and Form 42 title Physician s Permanent Impairment Evaluation. NON-NETWORK ACCESS Access within the Coventry MCP is mandatory. Referring to a non-network provider requires prior approval. The process for managing the referral requests may differ between approved plans. Please refer to the Coventry Comprehensive Client List at to contact the payors with questions regarding their specific process. For the Coventry MCP, providers should refer injured workers to other Coventry MCP providers whenever possible. There may be circumstances where a non-mcp provider may be needed. These circumstances include: For emergency or after-hours urgent care; If the injured worker s injuries and subsequent treatment occurred prior to the implementation of the Coventry MCP for that particular client; When a provider in the specialty needed is not available through the Coventry MCP; If the State instructs the injured worker to see a specific provider. UTILIZATION REVIEW Utilization Review is a required component of the MCP; however, the criteria for services requiring UR may be different from one approved MCP to another. Please refer to the Coventry Comprehensive Client List Coventry Integrated Network sm is a service mark of Coventry Workers Comp Services, Inc. (CWCS), a division of Coventry Health 5

6 6 ( UM/Pre-certification column) at to contact the payor with questions regarding their specific UR criteria. Coventry s Connecticut MCP requires providers to fax the request to Coventry s toll-free number at to receive approval for care and prior to referring care to other health care providers. For Coventry s MCP, Utilization Review is required for the following services: All non-emergency hospitalizations, outpatient surgery, and transfers between facilities. Psychiatric or psychological therapy or testing. All external and implantable bone growth stimulators. All chemonucleolysis, facet or trigger point injections. Repeat baseline diagnostic studies and laboratory testing. Biofeedback therapy. Physical therapy or occupational therapy. Work hardening. Work conditioning. All durable medical equipment. Nursing home, convalescent, residential and all home health care services and treatments. Pain clinics, chemical dependency clinics or weight loss clinics. All non-emergency dental services, including reconstructive dental care or dental appliances. Magnetic Resonance Imaging (MRI), Nerve Conduction/Velocity studies, CT scans, EMGs and Thermography. Video Fluoroscopy. Radiation or chemotherapy. Remember: All referrals should be made to other Coventry contracted providers whenever possible. APPEALS/DISPUTES The way each approved MCP manages appeals/disputes may differ from one plan to another. Please refer to the Coventry Comprehensive Client List at to contact the payors with questions regarding their specific appeal/dispute processes. For the Coventry MCP, providers should follow the instructions that accompany the non-certification recommendation in the event they wish to appeal a non-certification recommendation. Providers must exhaust the MCP's Appeal/Dispute process for before seeking review from the Workers' Compensation Commission. CASE MANAGEMENT AND RETURN TO WORK Case Management (CM) services are available under the MCP; however, the criteria for initiating CM may differ from one approved MCP to another. Please refer to the Coventry Comprehensive Client List at to contact the payor with questions regarding their specific CM services or criteria. For Coventry, the claims examiner may initiate Coventry s case management services for complex cases or when there is lost time. A Coventry Nurse may call to coordinate a treatment plan between the injured worker, provider, carrier/tpa and employer that is focused on preparing the injured worker to return to productivity as soon as medically feasible. Treatment plans should be practical and implementable. Throughout the process, emphasize the intent of treatment is to allow the injured worker to return to the worksite. Early return to work is recommended when medically

7 7 feasible under modified duty for a period of time. Clear communication of the treatment plan, including anticipated time frames to all involved parties, is essential to reaching the treatment goals. GRIEVANCES To file a grievance about any component of the CT MCP, please complete the grievance form on the attached page and send it to Coventry at the address noted below: Coventry Grievance Coordinator 3200 Highland Ave. Downers Grove, IL (800) All grievances must be submitted in writing within thirty (30) days from the event giving rise to the grievance. The written grievance must contain, at a minimum, sufficient information to allow Coventry to resolve the grievance, including: Provider s name and address Office contact and phone number Payor s name and address Date of the occurrence Employee s name and address Action desired by the provider Description of the event giving rise to the complaint Coventry generally resolves written grievances within 30 business days of receipt of the grievance. This period may be extended if we encounter a delay in receiving all the appropriate documents or records necessary to reach a decision on the grievance or if Coventry and the person filing the grievance agree in writing to an extension. If you have any questions about the grievance process, please contact Coventry's Grievance Coordinator at the number above.

8 8 Coventry Grievance Form (Please PRINT Clearly) DATE: INITIATOR S NAME: INITIATOR S PHONE #: ( ) CLIENT NAME: EMPLOYER NAME: INJURED WORKER S NAME (FIRST, M, LAST): DATE OF INJURY: SSN#: PROVIDER NAME (FIRST, M, LAST or Facility Name): PROVIDER TITLE: PROVIDER PHONE #: ( ) PROVIDER OR FACILITY ADDRESS (Street, City, State and Zip): PROVIDER OR FACILITY TAX ID #: DATE OF DISSATISFACTION: Please describe your complaint in detail below. Include dates, names, and the specific resolutions which you feel might remedy the situation. PLEASE ATTACH COPIES OF APPLICABLE MEDICAL RECORDS TO THIS FORM. THIS ISSUE INVOLVES: Service Medical Care Other REQUESTED ACTION: SIGNATURE: FORWARD FORM TO COVENTRY COMPLAINTS & GRIEVANCES, 3200 HIGHLAND AVE.., DOWNERS GROVE, IL complaintsandgrievances@cvty.com, Phone Number

9 9 EMPLOYEE MEDICAL & WORK STATUS FORM To Be Completed by Attending Physician/Office Employee Name (Last) (First) SS# (optional): D.O.B. Employer Department/Division Address/Location Initial or follow-up visit (circle one) Payer/Managed Care Plan Name Claim# Date of Injury/illness: / /. Date of this visit: / /. Employee will be seen in this office for F/U on / /. Physician aware of pre-existing condition? No Yes (If yes, explain) Employee s job (as stated by employee): Work Status: Having evaluated/treated this employee today, in my opinion: There is no change from prior visit. Employee may return to his/her regular work on / / without restriction. Employee can return to work on / / w/ the following functional capabilities: In an 8 hour workday, employee may: 1-2 hours 2-4 hours 4-6 hours 6-8 hours None Stand Walk Sit Bend/Squat Climb Reach Twist Crawl Drive Patient is able to lift Patient is unable to lift greater than pounds. Patient may use RIGHT LEFT BOTH foot/feet for repetitive movement as in operating foot controls. Patient may use RIGHT LEFT BOTH hands for repetitive single grasping fine manipulation pushing and pulling. The restrictions noted above are in effect until / /. Employee is Temporarily Totally Disabled until / / or pending recheck here on / /. Employee is on medication that will restrict his/her ability to work safely. Explain: I HAVE DISCUSSED THIS PATIENT S WORK RESTRICTIONS TELEPHONICALLY TODAY WITH HIS/HER EMPLOYER S REPRESENTATIVE, OR HAVE COMPLETED THE EMPLOYER S WORK STATUS FORM IN LIEU OF COMPLETING THE RESTRICTION PORTION OF THIS FORM. RELEASE TO REGULAR DUTY WITHOUT RESTRICTIONS AND/OR TOTAL DISABILITY MUST BE DOCUMENTED USING THIS FORM OR THE EMPLOYER S STANDARD FORM. DIAGNOSIS: TREATMENT PLAN: - Provider Name (Print) Provider Address: ProviderSignature: Date: / /. I have received a copy of this document. Employee Signature: Date: / /. Provider: Fax a copy to carrier, TPA, employer, or designee within one business day of visit Provider: File a copy in medical file. Provider: Give a copy to employee at time of visit.