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.(Minn. R. 5221.0430 - Subpart 1)
Change of 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. (Minn. R. 5221.0430 - Subpart 2)
See Direction of Care law.
Employee Selects from Network
The managed care plan must provide a description of the times, places, and manner of providing services under the plan, including a statement describing how the plan will ensure an adequate number of each category of health care providers is available to give employees convenient geographic accessibility to all categories of providers and adequate flexibility to choose health care providers from among those who provide services under the plan, in accordance with this chapter and MN Statutes, section 176.1351 , subdivisions 1, clauses (1) and (2), and 10. The MCP must include at a minimum, and provide to an employee when necessary under MN Statutes, section 176.135, subdivision 1, the following types of health care services and providers, unless the MCP provides evidence that a particular service or type of provider is not available in the community: medical doctors, including the following specialties: specialists in at least one of the following fields: family practice, internal medicine, occupational medicine, or emergency medicine; orthopedic surgeons, including specialists in hand and upper extremity surgery; neurologists and neurosurgeons; and general surgeons; chiropractors; podiatrists; osteopaths; physical and occupational therapists; psychologists or psychiatrists; diagnostic pathology and laboratory services; radiology services; and hospital, outpatient surgery, and urgent care services. (Minn. R. 5218.0100 Subpart 1(E)
The MCP must include procedures to ensure that employees will receive services in accordance with sub-items (1) to (7): (1) Employees must receive initial evaluation by a participating licensed health care provider within 24 hours of the employee's request for treatment, following a work injury. (3) Following the initial evaluation, upon request, the employee must be allowed to receive ongoing treatment from any participating health care provider as the employee's primary treating health care provider in one of the disciplines in units (a) to (e), if the provider is available within the mileage limitations in sub-item (7) and the treatment is required under MN Statutes, section 176.135, subdivision 1, is within the provider's scope of practice, and is appropriate under the standards of treatment adopted by the MCP or the standards of treatment adopted by the commissioner under MN Statutes, section 176.83, subdivision 5: (a) medical doctors; (b)chiropractors; (c) podiatrists; (d) osteopaths; or (e)dentists. An evaluating provider may also be offered as a primary treating provider. (7) Employees must have access to the evaluating and primary treating health care provider within 30 miles of either the employee's place of employment or residence if either the residence or place of employment is within the seven-county metropolitan area. The seven-county metropolitan area includes Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties. If both the employee's residence and place of employment are outside the seven-county metropolitan area, the allowable distance is 50 miles. If the employee requires specialty services that are not available within the stated mileage restriction, the managed care plan may refer the employee to a provider outside of the stated mileage restriction. If the employee is medically unable to travel to a participating provider within the stated mileage restriction, the managed care plan shall refer the employee to an available nonparticipating provider to receive necessary treatment for the injury. (Minn. R. 5218.0100 Subpart 1(F))
Change of Provider
The managed care plan must include procedures to ensure that employees will receive services in accordance with sub-items (1) to (7):
(5) Employees must be allowed to change primary treating providers within the managed care plan at least once without proceeding through the MCP's dispute resolution process. In such cases, employees must make a request to the MCP for a change in their treating health care provider. A change of providers from the evaluating health care provider in sub-items (1) and (2) to a primary treating doctor for ongoing treatment is not considered a change of doctor, unless the employee has received treatment from the evaluating health care provider more than once for the injury. (Minn. R. 5218.0100 Subpart 1(F))
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. (Minn. R. 5221.0430 Subpart 4.)
See Direction of Care law for network access requirements.
The information on this website constitutes summary information only and does not constitute legal advice. Review of the full text of the referenced statutes and regulations may be necessary. Coventry Health Care Workers' Compensation, Inc. makes no representations or warranties about the accuracy of the information contained on this website.