PROVIDER REFERENCE MANUAL KENTUCKY MANAGED HEALTH CARE PROGRAM (MHCP)

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1 PROVIDER REFERENCE MANUAL KENTUCKY MANAGED HEALTH CARE PROGRAM (MHCP) (800) Coventry has developed this manual for Network Providers participating in the Coventry MHCP to assist in understanding the provider s role and responsibility under the MHCP. As a Coventry participating provider in the MHCP, this program brings increased opportunity for business to render medical care to injured workers. This program is designed to assist workers compensation insurers in controlling health care costs while maintaining quality medical standards. NETWORK OPTIONS Coventry uses this Provider Reference Manual for its Fully Bundled KY MHCP. In addition, Coventry leases its Network to customers (Network Only) to use in their certified KY MHCP. This book is designed to supply the provider with information about which entity to contact in support of either program. Network Participation - Providers may contact the Coventry MHCP, by calling the toll-free number at the top of the page to verify network participation, ask questions about the MHCP services and learn about Coventry customers using the MHCP. This toll-free number is available 24 hours a day. After normal business hours, you may leave a message and you will be contacted during the next business day. All provider questions relating to Network participation, rates for PPO services or changes to Provider Information, Ftins or other demographic detail should be directed to Coventry s Network Call Center at Fully Bundled When Coventry is the certified entity, calls related to utilization review, case management, complaints and grievances should be sent to Coventry. Questions relating to eligibility, compensability or payment will be sent to the Adjuster. Network Only When the client is the certified entity, other vendors are providing utilization review and case management. All questions related to these services in addition to complaints and grievances, eligibility, compensability or payment should be directed to the Carrier or Adjuster.

2 CARRIER VOLUNTARY PROGRAM MANDATORY FOR INJURED WORKERS WHEN SELECTED Carrier participation in the Coventry MHCP is voluntary; however, once an insured elects to use the program, injured workers are required to receive treatment from the MHCP. For those customers using the MHCP, there are limited circumstances, as described further down in this document, where access outside the MHCP is allowed. The Certified entity must supply the injured worker with communication about how to use the MHCP. Each certified entity is different. For Coventry, we supply Injured Workers with an Employee Notice to explain the rules and responsibilities under the MHCP. A copy of the Coventry Employee Notice is available upon request. For copies of documents that other certified entities supply to their Injured Workers, please contact the adjuster. DIRECTION Insurers who have elected to use the Coventry MHCP must actively channel injured workers to participating Network providers. Insurers use various ways to channel, including: Through worksite posters Through Coventry s website at Through the Employee Notice distributed to the injured worker at the time of injury. Once the injured worker is off work, insurers work with the injured workers to select a Gatekeeper physician. Injured workers may choose any gatekeeper from within the MHCP. Once chosen, the carrier confirms the gatekeeper by sending the injured worker an ID card. For copies of documents that other certified entities supply to their Injured Workers, please contact the adjuster. GATEKEEPER PROVIDERS Gatekeeper physicians are physicians and surgeons, psychologists, optometrists, dentist, podiatrists, and osteopathic and chiropractic practitioners acting within the scope of their license issued by the Commonwealth. Gatekeeper responsibilities include: Acting as a gatekeeper physician with primary responsibility for treatment of the workers compensation injury; and, Maintaining a treatment plan for the injured worker in accordance with 803 KAR 25:096(6); and, Agreeing to the terms and conditions of the MHCP; and Referring to MHCP providers for specialty care or diagnostic services or to non-network services if an MHCP provider specialty is not available. NETWORK REQUIREMENTS

3 To ensure that all parties achieve maximum benefits through this program, MHCP participating providers must: Accept the contract rate as payment in full. See injured workers as soon as possible. Encourage injured workers return to work at the earliest opportunity where medically appropriate. Work with Coventry or our Clients utilization management programs. The Coventry UR centers are noted below. If you are uncertain who to contact for UR, contact the adjuster.. Provide detailed verbal and written reports as indicated, and upon request, about the capabilities and limitations of the injured worker. Refer to other network providers when available. Document and maintain injured workers treatment plans consistent with 803 KAR 25:096(6). Coventry Tampa, FL UR Center Tel: (800) Fax: (877) Coventry Hazelwood, MO UR Center (St. Louis) Tel: (800) Fax: (888) or (800) NON-NETWORK EXCEPTIONS There are limited exceptions to using non-network providers. Access to non-network providers requires approval beyond emergency care. Below are the circumstances under which non-network access will be approved: 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; or To obtain a second opinion when a managed care plan physician recommends surgery. To obtain approval for any non-network acceptions, contact the Adjuster. REFERRALS TO SPECIALIST To refer to a specialist, contact Coventry or the certified entity for approval. Referrals should be directed into the Coventry MHCP Network. To locate a provider within the MHCP, go to or call Coventry at If you are uncertain whether the carrier is part of a certified KY MHCP, contact the Adjuster. UTILIZATION REVIEW The KY MHCP requires the following 4 scenarios be subjected to Utilization Review (UR): All hospitalizations; All surgeries;

4 When a claim reaches >$3,000 in medical costs; and When the claim reaches over 30 days of lost time. In addition, Coventry suggests UR on these additional triggers: PT > 6 visits all other states Inpatient hospital stays All surgeries IDET (Intradiscal Electrothermal Therapy) Repeat Diagnostics Chemical Dependency Programs Weight Loss Programs Work Hardening/Work Conditioning > 2 wks Chiro treatments > 6 visits Gym Memberships Acupuncture > 3 visits Interferential Units Bone Growth Stimulators Psych Testing Inpatient Pain Management Programs Neurocognitive Rehab Biofeedback Myelograms Discograms DME > $500 (Ex. custom wheel chairs, hospital beds, neuromuscular stimulators) Experimental Procedures (Prolotherapy, disc replacement surgery) Nursing Home Admissions Home Health Aides Rehab Services Vax-D (non-surgical spinal decompression therapy) For those customers using the Coventry Utilization Review, please call: Coventry Tampa, FL UR Center Tel: (800) Fax: (877) Coventry Hazelwood, MO UR Center (St. Louis) Tel: (800) Fax: (888) or (800) Some insurers who are their own certified entity using Coventry s Network for their MHCP may require all services be authorized prior to treatment. Please contact the Adjuster to confirm whom to call and which services require UR. *Remember: All referrals should be made to other Coventry contracted providers whenever possible. To locate a provider within the MHCP, go to If you need assistance with finding a specialist within the network, you may call the Adjuster or Coventry at CASE MANAGEMENT In addition to Utilization Review, Coventry recommends insurers initiate Case Management services for the following triggers: All Lost Time Claims whether assessed on initial claim capture or if MO converts to LT MO Claims that have pending surgeries indicating likely future LT MO Claims with multiple diagnoses IW with multiple claims with same employer IW with multiple providers Pre-existing conditions complicating recovery

5 Pending minor surgery (no anticipated LT) or until the claim converts to LT Repetitive Trauma Joint Injuries Fractures Re-injury of same body part History of previous industrial injury (prior claims that are settled) Injury that occurs in EE s first 90 days of employment Diagnostic referrals PT/OT/Chiro referrals Specialist referral Participating providers may receive inquiries from Coventry or other vendor nurses associated with clients using their own MHCP program. Please work with these Nurse Case Managers to mutually reach the goal of return to work for the injured workers. These Nurse Case Managers will be inquiring about the following information which may include, but is not limited to: History of injury Diagnosis Co-morbidities or anticipated complications that might delay recovery or return to work Past medical treatment, dates, and results of testing Current treatment plan and employee status Future anticipated treatment Modified duty/full duty requirements with current employer Current work status Employee s functional capabilities Next office visit Projected MMI In the event you are uncertain who to contact for Case Management services, please contact the Adjuster. COMPLAINTS AND GRIEVANCES Key Contacts: For clients using the Coventry MHCP, please contact Coventry at For clients who are the certified KY MHCP themselves, please contact the adjuster for information on Complaints & Grievances. Communication As required under 803 KAR 25:110 Section 10, an MHCP is required to have a comprehensive, expeditious, informal process to resolve disputes by employees and providers relative to medical services provided by Coventry participating providers. In addition, the MHCP must communicate the complaints and grievances process within communication materials to injured workers and providers. Injured Workers receive this at the time

6 of injury as part of their Employee Notice relating to the rules and responsibilities under the MHCP. A sample copy of the Coventry Employee Notice is available upon request. For Coventry, the process is defined within this provider manual and referenced in the provider contracts. A copy of Coventry s comprehensive policies and procedures for complaints and grievances are available upon request by calling Coventry at For information on a client s MHCP, relating to Complaints & Grievances, contact the Adjuster. Process For complaints involving a utilization review process, denial of services, call the Adjuster or Utilization Review vendor for an appeal. For complaints involving participating providers, contact Coventry s Provider Services at Coventry s WC Customer Service Team will make every effort to resolve the issue as quickly as possible. If a provider wishes to file a grievance, the provider must file the grievance in writing and forward directly to the certified entity. For Coventry s MHCP, mail the grievance to: Coventry, Attn: Grievance Coordinator, 3200 Highland Ave., Downers Grove, IL Phone (800) and Fax [email protected]. To file a grievance with another certified entity, contact the adjuster to obtain the contact name and address. Include in the Grievance The written grievance must contain, at a minimum, sufficient information (see below) to allow the Provider Relations Manager to address the grievance and must be filed within thirty (30) days from the event giving rise to the grievance. The grievance should clearly state the following: Provider s name and address Office contact and phone number Payer 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 The MHCP managing the grievance is required to render a written decision upon a written grievance within thirty (30) days of receipt of the grievance. In addition, the MHCP will maintain records for two (2) years of each formal grievance which shall include the following: A description of the grievance; The employee's name and address;

7 Names and addresses of the health care providers relevant to the grievance; The managed health care system's and employer's name and address; and A description of the managed health care system's findings, conclusions, and disposition of the grievance. In the unlikely event you are dissatisfied with the resolution; you may file a written request for resolution within 30 days of the date of our final decision to an Administrative Law Judge. This written request should be sent to the: Department of Workers Claims Prevention Park 657 Chamberlain Ave Frankfort, KY Upon review by an administrative law judge the complainant shall be required to prove that the system's final decision is unreasonable or otherwise fails to conform to KRS Chapter 342.