N.H. Admin. Code § Lab 703.01 - Necessary Components

(a) No managed care program in workers' compensation shall be offered or used in this state unless the commissioner finds that the program meets the requirements of (b)-(p) below.

(b) The network of health care providers shall be sufficiently comprehensive with respect to both geography and medical specialties.

(c) A network shall be deemed comprehensive if it includes 2 or more vocational rehabilitation providers, for injuries covered by the program.

(d) A network of health care providers shall be sufficiently comprehensive with respect to geography and medical specializations when the commissioner finds that it offers a covered employee in each county a choice of 2 or more of each of the following health care providers:

(1) Chiropractic services;

(2) Family practice or occupational medicine physicians or internal medicine physicians;

(3) Neurologists;

(4) Neurosurgeons;

(5) Ophthalmologists;

(6) Occupational therapists:

(7) Physical therapists;

(8) Orthopedic surgeons;

(9) Physiatrist or rehabilitation medicine physicians; and

(10) Spine surgeons.

(e) In cases where 2 or more of such choices are not available in each county covered by the proposed network, the program shall be considered comprehensive if it allows access to such medical services in an adjacent county.

(f) The program may include additional healthcare providers and medical services other than those listed in part (d) above, provided the injured employee has a choice of at least 2 such providers within the radius of 25 miles from the injured employee's residence. An injured employee shall be required to use as part of the network only those health care providers.

(g) The program shall provide for treatment and remedial services, nursing, medicines and mechanical and surgical aids outside of the network under the following circumstances:

(1) If the necessary services or aids are not available to the employee within the network, or if emergency circumstances prohibit use of the network;

(2) When transfer of care outside the network is recommended by an in-network provider, the reasonableness of future treatment shall be determined by reviewing the physician's recommendations and the network's availability to assist the employee in obtaining the needed services and aids within the network;

(3) If emergency circumstances in which treatment or aids required to protect the health of an injured employee are required to be applied or administered immediately and without opportunity to notify the person or persons designated for such notification by the program or to follow the directive of such person or persons if such notification occurred;

(4) If an injured employee has been treated by a provider who is not a member of the network to treat a recurrence or aggravation of an injury treated by such provider within the prior 6 months, as long as such provider complies with all the terms, conditions, protocols, referral procedures, and levels of reimbursement established by the network; or

(5) If unique circumstances based upon an individual case are sent in writing to the commissioner showing that the requested services or aids were not available within the network the commissioner shall investigate the circumstances and the network's resources to determine if it is necessary to seek out of network services and shall advise the parties of the decision.

(h) The program shall include a process for determining professional qualifications of health care providers in the network. Internal credentialing procedures shall be sufficient, as long as the data utilized in the process of credentialing shall be in enough detail to enable the commissioner to verify the validity of the process.

(i) The program shall provide for acceptable quality assurance measures. Acceptable quality assurance measures means regularly utilized procedures to assure that medical providers shall be continually qualified by training and experience to administer the treatment or aids offered to covered employees. Additionally, following such treatment and aids, medical records shall be retained and available for inspection. These measures shall include the use of a quality assurance committee which regularly inspects such evidence or records and the quality of care being delivered by the program.

(j) The program shall include both in-patient and out-patient case management, medical, vocational and rehabilitation case management that includes prospective and concurrent review, discharge planning, work-hardening and return to work programs. The program shall include a sufficient number of injury management facilitators who shall be qualified by reason of education, experience and training to manage an injured employee's medical care by interacting with the employee, treating physician, other healthcare providers and the employer to facilitate the expeditious intervention of medical treatment and an early return to work.

(k) Each managed care organization shall have a sufficient number of injury management facilitators. This number shall include at least one resident injury management facilitator with a business office in New Hampshire.

(l) In determining what constitutes a sufficient number of injury management facilitators, the following shall be used to determine compliance:

(1) The number of employers subscribing to the program:

(2) The approximate number of employees covered by the program; and

(3) The average number of cases referred to each injury management facilitator annually.

(m) At least one in every 5 injury management facilitators shall be a resident injury management facilitator with a business office in New Hampshire.

(n) Injury management facilitators employed or contracted by the managed care organization shall be qualified, with such qualification valid for only 5 years and subject to requalification an unlimited number of times, in one or more of the following ways:

(1) By holding a license as a registered nurse issued by the New Hampshire board of nursing and having at least one year of experience in the medical management of workers' compensation claims in New Hampshire or in lieu of experience has completed a training program offered by the department;

(2) By holding a designation as a certified case manager issued by The Commission on Case Manager Certification, and having at least one year of experience in the medical management of workers' compensations claims in New Hampshire or in lieu of the experience has completed a training program offered by the department;

(3) By holding a designation as a certified rehabilitation counselor issued by The Commission on Rehabilitation Counselor Certification, and having at least one year of experience in the medical management of workers' compensation claims in New Hampshire or in lieu of the experience has completed a training program offered by the department; or

(4) By holding a designation as a certified disability management specialist issued by The Commission on Disability Management Specialists, and having at least one year of experience in the medical management of workers' compensation claims in New Hampshire or in lieu of the experience has completed a training program offered by the department.

(o) The program shall provide an employee with access to a second medical opinion, inside or outside the program, regarding diagnosis or the proper course of treatment, and adequate methods for resolving conflicting medical opinions. Access to a second medical opinion shall be warranted when following an examination and diagnosis by a medical provider, the employee remains uncertain about the nature of the injury or the proper course of treatment necessary to cure or alleviate it.

(p) The program shall provide a method for prompt and impartial resolution of questions or disagreements between a healthcare provider and the managed care organization.

Notes

N.H. Admin. Code § Lab 703.01

#5788, eff 2-17-94, EXPIRED: 2-17-00

New. #7212, INTERIM, eff 3-2-00, EXPIRED: 6-30-00

New. #7338, eff 8-2-00; ss by #9217, eff 8-1-08; amd by #10038, eff 12-1-11

Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12013, Effective 10/25/2016, Expires 12/25/2026.