Enrollment in a managed care organization (MCO)

What is a managed care organization?

A managed care organization (MCO) is a group of medical providers who have obtained certification from the Workers’ Compensation Division. The MCO contracts with insurers to manage and provide medical care to workers with work-related injuries.

I received a letter from my insurer enrolling me in a managed care organization. What does this mean?

If your employer is covered by an insurer who has contracted with a managed care organization (MCO), the insurer may enroll you in an MCO at any time after your injury. The insurer must provide you with a written notice of enrollment that contains all required enrollment information, and includes either a written list of the MCO's eligible attending physicians or a web address for you to access the list.

Am I required to treat with an MCO panel provider?

Until you are enrolled, you can treat with any health care provider who qualifies as an attending physician. After enrollment, if you have a family doctor who qualifies as a primary care physician or authorized nurse practitioner and meets certain requirements, they can continue to treat you by agreeing to the MCO's rules, terms, and conditions.

What if my attending physician is not an MCO panel provider and does not qualify to continue to treat me as a primary care physician or authorized nurse practitioner?

You can continue to treat with your non-MCO provider for up to 14 days from the mailing date of your enrollment letter. However, at the end of the 14 days, the insurer will not reimburse the non-MCO provider for medical services and your time-loss benefits may be suspended, if applicable.

Can I appeal an MCO’s medical decisions?

Yes. If an MCO disapproves a medical service, or you disagree with an MCO decision, you can appeal that decision. The MCO must provide written notice of its decision to all parties and include the process for appealing the decision. When an MCO receives a complaint or dispute that is not included in its dispute resolution process, the MCO must provide you notice within seven days of your right to request review by the Workers' Compensation Division.