Rule 55: Managed Care — Notice to Employee
Sections 48-120, 48-120.02, 48-163, R.R.S. 2021.
Effective date: October 27, 1998.
Words in italics are defined in Rule 49.
An employee is not required to receive services under a managed care plan until the insurer, risk management pool, or self-insured employer gives the employee notice of the information listed below in this rule. Individual notice of such information must be given at the time the employee becomes subject to the contract (see Rule 53,I). The notice must include the following information:
Rule 55(A)
A. The employer is covered by the named managed care plan to provide all required treatment for work-related injuries after a specified date. An employee sustaining an injury prior to the specified date is required to receive services under the plan only if the employee changes physicians.
Rule 55(B)
B. The toll free telephone number of the managed care plan where the employee can receive answers to questions about managed care.
Rule 55(C)
C. The employee may receive treatment from a medical doctor, chiropractor, podiatrist, osteopath, or dentist under the plan, if the treatment is available within the community and the scope of practice of the physician is appropriate for the treatment of the injury in question.
Rule 55(D)
D. How the employee can access care under the managed care plan, how the employee can identify eligible physicians, and the toll free 24 hour telephone number of the managed care plan that informs employees of available services.
Rule 55(E)
E. The employee may be required to receive services from a participating physician under the managed care plan except in the following circumstances:
1. if the employee or an immediate family member has treated with a physician prior to the date of injury who can provide treatment appropriate for the injury in question, if the employee selects such physician according to rules established by the court, if such physician agrees to refer the employee to the managed care plan for any other treatment that the employee may require, and if such physician agrees to comply with all of the rules, terms, and conditions of the managed care plan; or
2. if the employer fails to notify the employee of the right to select a family physician according to the rules established by the court;
3. for emergency medical treatment; or
4. in cases of injury requiring dismemberment or injuries involving major surgical operation, if the employee selects the physician to perform the operation and such physician agrees to refer the employee to the managed care plan for any other treatment that the employee may require, and if such physician agrees to comply with all of the rules, terms, and conditions of the managed care plan; or
5. after compensability has been denied by the insurer, risk management pool, or self-insured employer; or
6. if there is no participating primary treating physician available within the mileage restrictions established in Rule 53,E,7 of the Rules of Procedure of the Nebraska Workers’ Compensation Court.