|
This table identifies specific regulations for managed care
arrangements. |
|
State |
Timeframe within which Worker Must Be Seen After Request for Treatment |
Details Defining Adequate Number of Providers within a Geographical
Location |
Details of Utilization Review Criteria |
Definition of Medical Care Coordination and/or Case Management |
Required Use of Treatment Guidelines |
Other |
|
Review of Treatment Plans for Reasonableness and Necessity |
Review of Individual Services for Reasonableness and Necessity |
Review of Inpatient and
Outpatient Hospitalizations for Reasonableness and Necessity |
Review of Outpatient and Ambulatory Surgery for Reasonableness and
Necessity |
|
Prospective |
Retrospective |
Prospective |
Retrospective |
Prospective |
Retrospective |
Prospective |
Retrospective |
|
Concurrent |
Concurrent |
Concurrent |
Concurrent |
|
Sample State 1 |
No later than the last day of the third week after the date of request |
See TIC 1305.302 Accessibility and Availability Requirements |
x (15) |
x |
x |
x |
x |
x |
x |
x |
x |
x |
x |
x |
Network shall have a medical case management program with certified case
managers. Case managers shall work with treating doctors, referral
providers and employers to facilitate cost-effective care and employee
return to work |
Network may choose |
|
|
Sample State 2 |
None |
Yes |
|
|
|
x |
x |
x |
x |
x |
x |
x |
x |
x |
None |
None |
|
|
Notes: |
|
