Managed care organization panel size and composition
A managed care organization (MCO) must have a panel of medical service providers of adequate size and variety to ensure enrolled workers receive quality medical care and services in a timely, effective, and convenient manner. The Workers' Compensation Division oversees the MCO's compliance in the areas of treatment access and provider coverage.
On a 24-hour basis, MCOs must provide enrolled workers with information regarding medical services available within the MCO, including the worker's right to receive emergency or urgent care. The MCO also must provide its regular working hours for enrolled workers needing help with choosing an attending physician.
Enrolled workers should be able to access medical providers, including attending physicians, within a reasonable distance from the worker's place of employment, considering the normal patterns of travel.
An MCO is required to have a provider panel in its GSA that includes at least three providers in each of the following eight categories: acupuncturist, chiropractor, dentist, medical doctor, naturopath, optometrist, osteopath, and podiatrist. This requirement must be met, unless the MCO shows evidence that there is not an adequate number of providers in a given category able or willing to become members of the MCO. If the MCO has fewer than three providers in a particular required category, the worker is permitted to treat with an off-panel provider in order to obtain the services of a provider in that particular category.
Although authorized nurse practitioners (ANPs) are not a required medical service provider type, an MCO must have three ANPs on its panel in a geographic service area. Otherwise, the worker may choose to treat with an off-panel authorized nurse practitioner, within the statutory limitations provided for treatment by an ANP.
Questions? Contact us at 503-947-7606 or e-mail firstname.lastname@example.org.