Rule 61: Managed Care — Suspension; Revocation

A. Criteria. The certification of a managed care plan may be suspended or revoked by the court if:

1. the plan for providing services or a contract with the insurer, risk management pool, self-insured employer, or health care provider fails to meet the requirements of Rule 51 through Rule 61 or sections 48-120 and 48-120.02 or;

2. service under the plan is not being provided according to the terms of the plan; or

3. any false or misleading information is submitted by the managed care plan or participating provider; or

4. the managed care plan continues to use the services of a health care provider whose license, registration, or certification has been suspended or revoked.

B. Complaints; investigation. Complaints pertaining to violations of Rule 51 through 61 or sections 48-120 and 48-120.02 by the managed care plan shall be directed in writing to the court. On receipt of a written complaint, or after monitoring the managed care plan operations, the court may investigate the alleged violation. The investigation may include, but shall not be limited to, request for and review of pertinent managed care plan records. If the investigation reveals reasonable cause to believe that there has been a violation, the certification may be suspended or revoked.

C. Immediate Revocation. Notwithstanding Rules 61,A and 61,B above, in any case where the court finds a serious danger to the public health or safety the court may immediately revoke the certification of the managed care plan.

D. Effects.

1. An employee is no longer required to receive services under a managed care plan if the managed care plan’s certification is revoked.

2. Any contractual obligations of an insurer, risk management pool, or self-insured employer to allow a managed care plan to provide medical, surgical, or hospital services for employees pursuant to the Nebraska Workers’ Compensation Act shall be null and void upon revocation of the certification of the managed care plan.

3. Any contractual obligations of a health care provider or other entity to deliver medical, surgical, or hospital services pursuant to the Nebraska Workers’ Compensation Act, or to

comply with any rules, terms, and conditions of the managed care plan or to make referrals into the managed care plan shall be null and void upon revocation of the certification of the managed care plan.