WEST VIRGINIA
Employee Selects
If the employer does not provide a managed health care plan or program, the claimant may select his or her initial health care provider for treatment of a compensable injury or disease, except as provided under subdivision (3) of this subsection. If a claimant wishes to change his or her health care provider and if his or her employer has established and maintains a managed health care plan, the claimant shall select a new health care provider through the managed health care plan. A claimant who has used the providers under the employer's managed health care plan may select a health care provider outside the employer's plan for treatment of the compensable injury or disease if the employee receives written approval from the commission to do so and the approval is given pursuant to criteria established by rule of the commission. (3) If the commission enters into an agreement which has been approved by the board of managers with a managed health care plan, including, but not limited to, a preferred provider organization or program, a health maintenance organization or managed care organization or other health care delivery organization or organizations or other medical cost containment relationship with the providers of medical, hospital or other health care, then: (A) If an injured employee's employer does not provide a managed health care plan approved by the commission for its employees as described in subdivision (2) of this subsection, the commission may require the employee to use health care providers authorized by the commission's managed health care plan for care and treatment of his or her compensable injuries; (W. Va. Code § 23-4-3 (b)(2),&(3)

Change of Provider
If a claimant seeks to change his or her initial choice of health care provider where neither the employer nor the commission had an approved health care management plan at the time the initial choice was made, and if the claimant's employer does not provide access to such a plan as part of the employer's general health insurance benefit, then the claimant shall be provided with a new health care provider from the commission's managed health care plan available to him or her. (W. Va. Code § 23-4-3 (b)(3)(B))

Injured workers must request authorization from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, to change the treating physician of record in their claim. This rule does not apply in the following cases:
a. Care transferred after initial emergency or first aid treatment if done so within 30 days of the date of injury;
b. Care transferred to a specialist by the original treating physician; or
c. Care where an unforeseen emergency develops which requires special facilities and skills are not available to the treating physician or hospital. (W. Va. CSR § 85-20-6 6.7.)

Panels
Not addressed

Panel Provisions
See Direction of Care law.

WEST VIRGINIA MHCP
Employee Selects from Panel
A self-insured employer or a private carrier may: (2) Require employees to obtain medical and health care services for their industrial injuries from those organizations and persons with whom the self-insured employer or private carrier has contracted or as the self-insured employer or private carrier otherwise prescribes. (W. Va. Code § 23-2C-17(d))

The provisions of this subsection shall not prohibit an employer, the successor to the commission, other private carrier or self-insured employer from participating in a managed health care plan, including, but not limited to, a preferred provider organization or program or a health maintenance organization or managed care organization or other medical cost containment relationship with the providers of medical, hospital or other health care. An employer, successor to the commission, other private carrier or self-insured employer that provides an MHCP approved by the commission or, upon termination of the commission, the insurance commissioner, for its employees or the employees of its insured may require an injured employee to use health care providers authorized by the MHCP for care and treatment of his or her compensable injuries. (W. Va. Code § 23-4-3 (b)(2))

All MHCPs submitted for approval shall include the following features:
b. The injured worker shall be allowed a reasonable choice of providers within the plan
providers within the plan
c. Adequate specialty and subspecialty providers, and general and specialty hospitals must be provided for to afford employees reasonable choice and convenient geographic accessibility to all categories of licensed care. Primary care available within 75 driving miles of the employer's facility is presumed to be geographically reasonable unless the standard of care within the community extends this distance. The availability of secondary and tertiary care shall not be governed by the 75 mile standard; (W. Va. CSR § 85-21-4.1(b)-(c))

Change of Provider
If a claimant wishes to change his or her health care provider and if his or her employer has established and maintains a managed health care plan, the claimant shall select a new health care provider through the managed health care plan. A claimant who has used the providers under the employer's managed health care plan may select a health care provider outside the employer's plan for treatment of the compensable injury or disease if the employee receives written approval from the commission to do so and the approval is given pursuant to criteria established by rule of the commission. (W. Va. Code § 23-4-3. (b)(2))

Panels
Not addressed

Panel Provisions
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.