State Rules
Preface
This document includes information on state rules governing the use of panels and directories. The information is provided as a convenience to the user. While Zenith strives to maintain the accuracy of the information provided for each jurisdiction, Zenith does not warrant the accuracy of the information provided. The information also is not intended to replace or serve as legal advice. Users are encouraged to consult their own legal counsel.
WORKERS' COMPENSATION PROVIDER RULES FOR ALASKA
Overview:
In Alaska, the employee designates the physician for initial medical treatment. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may designate a licensed physician to provide all medical and related benefits. Alaska Stat. § 23.30.095 (a).
Provider Change and Provider Referrals:
General Rule: The employee may make one change in treating physician without the written consent of the employer. Further changes require employer's written consent. Referrals to specialists are not considered a change in treating physician. Alaska Stat. § 23.30.095 (a).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR ARIZONA
Overview:
The employer may select the initial provider in the State of Arizona, therefore, one (1) provider may be listed on the panel for initial care. After the initial visit, the employee may select a physician as indicated above.
Initial Choice of Provider:
General Rule: The employer/insurer may direct the injured worker to a physician for a one time evaluation. Go to the Industrial Commission of Arizona for details: http://www.ica.state.az.us/HomePage/HOME_FAQs.aspx.
Provider Change and Provider Referrals:
General Rule: The employer/insurer may choose the initial treating provider for the first visit. After one visit to the initial treating provider, the employee may return to that physician or pursue treatment with a physician of his/her choice. Subsequent changes in primary treating provider must be approved by the current treating physician, insurance carrier, or Industrial Commission. A.R.S. §§ 23-1070, 23-1071(B).
Panels and Directories:
The employer may not direct medical care except for the first visit. Therefore, panels and directories after the first visit should not be used in Arizona (except for informational purposes only which shall not limit the employee's choice of provider). There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 1 Initial Care Clinics/Primary Care Physician
- 1 Acute Care Hospital
- 1 Initial Care Clinics/Primary Care Physician
- 1 Acute Care Hospital
WORKERS' COMPENSATION PROVIDER RULES FOR ARKANSAS
Overview:
In Arkansas, the employer may select the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. If the employee wishes to change, they must Petition the Arkansas Workers' Compensation Commission for a one-time change as indicated above.
Initial Choice of Provider:
General Rule: The employer or insurer may choose the provider for initial care. A.C.A. § 11-9-508 (d) (5) (A).
Provider Change and Provider Referrals:
General Rule:
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 2 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR CALIFORNIA
Overview:
Zenith manages the Zenith Medical Provider Network ID #3142 (ZMPN). The ZMPN is comprised of a subset of providers participating in the Anthem network in California and providers who contract directly with Zenith.
Where an employee is subject to the ZMPN and the employer controls medical direction for the initial visit, one (1) provider may be listed on the panel for the initial visit. However, the employee must be provided access to providers within the ZMPN as indicated below for subsequent care.
Where an employee is not subject to the ZMPN, one (1) provider may be listed on the panel for the initial visit. However, the employee may treat with a provider of the employee's choice after thirty (30) days from the date the injury was reported, as indicated below.
Initial Choice of Provider:
Employees subject to the ZMPN: Unless the employee has pre-designated a provider, the employer controls medical direction for the first treatment visit. The appointment for first treatment visit under the ZMPN must meet all applicable access standards and time frames. After the initial visit, the employee may change their treating provider, but only to another provider within the ZMPN. If the employee is unable to obtain from an ZMPN provider reasonable and necessary treatment within applicable access standards or time frames, the employee may treat with an appropriate non-ZMPN specialist within a reasonable geographic area. 8 CCR § 9767.5 (c). Emergency medical care does not require preauthorization and does not have to be provided by a ZMPN provider. 8 CCR § 9767.5 (j).
Employees NOT subject to the ZMPN: The employer has the right to direct non-emergency medical care for the first thirty (30) days from the date the injury is reported. LC § 4600(c).
Provider Change and Provider Referrals:
Employees subject to the ZMPN: The employee may change providers after the initial visit, but must choose a provider from the ZMPN. A chiropractor may only act as treating physician until the 24-visit cap is met (with some exceptions, e.g., post-surgical care, if authorized by Zenith). 8 CCR § 9767.6 (e). If the employee is not able to obtain from a ZMPN provider reasonable and necessary treatment within applicable access standards or time frames, the employee may obtain treatment from an appropriate non-ZMPN specialist within a reasonable geographic area. 8 CCR § 9767.5 (c). If the treating physician refers the employee to a type of specialist not included in the ZMPN, the employee may select a non-ZMPN specialist. 8 CCR § 9767.5 (i).
If the employee disputes the provider's diagnosis or treatment, the employee may obtain a second and third opinion from a provider in the ZMPN. 8 CCR § 9767.7(a). If, after the third opinion, the employee still disputes the diagnosis or treatment, the employee may request an Independent Medical Review. 8 CCR § 9767.7(h). During the second and third opinion process, the employee must continue treatment within the ZMPN. LC § 4616.3(c).
Employees NOT subject to the ZMPN: The employee may treat with a provider of the employee's choice within a reasonable geographic area after thirty (30) days from the date the injury was reported. LC § 4600(c).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form. Employees must be provided with unrestricted access to listings of providers within the ZMPN. Employees must have access to at least a regional area listing of ZMPN providers. In addition, the employer must maintain and make available its complete provider directory listing in writing and/or on the ZMPN's website (which must be clearly listed). An electronic directory listing must be provided on a CD, flash drive, email, or on a website if an electronic provider directory listing is requested by the employee. If a website URL address is provided, it must include any additional information needed to access the directory online including any necessary instructions and passcodes. 8 CCR § 9767.12(a) (2) (C).
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR COLORADO
Overview:
In Colorado, the injured worker selects a physician for initial medical treatment. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: When an employer has notice of an on-the-job injury, the employer or insurer shall provide the injured worker with a written list in compliance with a Designated Provider List (see below), from which the injured worker may select a physician or corporate medical provider. The Designated Provider List must be provided to the injured worker within seven (7) business days following the date the employer has notice of the injury, shall state the insurer's name, and provide 1-2 names of people that the insurer/employer designates as their representatives. 7 CCR 1101-3 Rule 8-2(A).
The Designated Provider List: In all cases of injury, the employer or insurer shall provide a list of at least two (2) physicians or two (2) corporate medical providers or at least one (1) physician and one (1) corporate medical provider, where available, in the first instance, from which list an injured employee may select the physician who attends said injured employee. The two (2) designated providers shall be at two (2) distinct locations without common ownership. If there are not two (2) providers at two (2) distinct locations without common ownership within thirty (30) miles of each other, then an employer may designate two (2) providers at the same location or with shared ownership interests. Upon request by an interested party to the workers' compensation claim, a designated provider on the employer's list shall provide a list of ownership interests and employment relationships, if any, to the requesting party within five (5) days of the receipt of the request. If the services of a physician are not tendered at the time of injury, the employee shall have the right to select a physician or chiropractor. For purposes of this section, "corporate medical provider" means a medical organization in business as a sole proprietorship, professional corporation, or partnership. C.R.S. § 8-43-404(5) (a) (I) (A).
In an emergency situation, the injured worker shall be taken to any physician or medical facility that is able to provide the necessary care. 7 CCR 1101-3 Rule 8-3(A). If the employer fails to comply with Rule 8-2, the injured worker may select an authorized treating physician of the worker's choosing. 7 CCR 1101-3 Rule 8-2(E).
Provider Change and Provider Referrals:
General Rule: Within ninety (90) days following the date of injury, but before reaching maximum medical improvement, an injured worker may request a one-time change of authorized treating physician (from the Designated Provider List or a physician who provides medical services for a designated corporate medical provider on the list) by completing and signing a form established by the division. 7 CCR 1101-3 Rule 8-5.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 1 Physician*
- 1 Corporate Medical Provider*
- 4 Physicians
- 2 Corporate Medical Providers
WORKERS' COMPENSATION PROVIDER RULES FOR CONNECTICUT
Zenith does not offer a managed care plan.
Overview:
In Connecticut, the employer chooses the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. After initial treatment, the employee must be provided a list with a minimum number of providers indicated below.
Initial Choice of Provider:
General Rule: Initial medical treatment is provided by an employer-designated physician. After initial medical treatment, the employee may choose an "attending physician" from an approved list (if the employer participates in an approved Medical Care Plan) or any medical practitioner who is licensed in Connecticut (if the employer does not participate in an approved Medical Care Plan). Conn. Gen. Stat. § 31-294d, Connecticut WC Commission Information Packet Rev. 02/28/2011.
Provider Change and Provider Referrals:
General Rule: The employee may change their attending physician by (a) obtaining a referral from their current attending physician, (b) obtaining approval from the insurer, or (c) obtaining approval from the Commissioner (Commissioner approval may also be granted at the request of the employer). If the employer participates in an approved Medical Care Plan, any such change must be to a provider that participates in the Medical Care Plan. Conn. Gen. Stat. § 31-294d, Connecticut WC Commission Information Packet Rev. 02/28/2011.
Panels and Directories:
Panels and Directories are allowed. Posting of a provider panel is required under a state certified managed care plan. There is no state required form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 0 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 0 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR DELAWARE
Overview:
In Delaware, the injured worker selects the initial treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may choose the provider for initial care. 19 Del. C. § 2323.
Provider Change and Provider Referrals:
General Rule: Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form. However, the employer or insurer must make clear that Panels and Directories do not limit an employee's choice of provider.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 General Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 General Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR DISTRICT OF COLUMBIA
Overview:
In District of Columbia (D.C.), the employee selects the initial treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The injured employee may choose a provider for initial care. If there is a need for immediate treatment and, due to the nature of an injury, the injured employee is unable to select a physician, the employer may select a physician to provide initial treatment to the employee (such physician shall not be considered to have been selected by the employee). D.C. Code § 32-1507(b) (3), CDCR 7-212.2-3.
Provider Change and Provider Referrals:
General Rule: Once a medical care provider is selected to provide treatment, an injured employee shall not change to another medical care provider or hospital without authorization from the insurer or the Office (of Workers' Compensation), except in an emergency. Notice of the provision of emergency care shall be provided to the insurer and the Office within a reasonable time after the care is rendered. CDCR 7-212.12. If the injured employee is not satisfied with their medical care, a request for a change may be made to the Office. The Office may order a change where it is found to be in the best interest of the employee. CDCR 7-212.13.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form. However, the employer or insurer must make clear that Panels and Directories do not limit an employee's choice of provider.
Panel Minimum & Maximum Provider Content:
- 1 Initial Care Clinic/Primary Care Physician
- 0 General Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 General Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR FLORIDA
Zenith does not offer a Managed Care Arrangement
Overview:
In Florida, the employer selects the initial treating provider. Therefore, one (1) provider may be listed on the panel for initial care. However, if the employee wishes to change providers, he or she must be provided a list with a minimum number of providers indicated below.
Initial Choice of Provider:
General Rule: The employer or insurer may choose the provider for initial care. Fla. Stat. § 440.13 (2) (a).
Under a Managed Care Arrangement (MCA): An employee subject to a MCA must receive medical services pursuant to such MCA contract as long as the employer and insurer have provided adequate notice to the employee. Any treatment outside the arrangement is not compensable unless preauthorized by the insurer. Fla. Stat. § 440.134 (17).
Provider Change and Provider Referrals:
General Rule: The employee is entitled to one (1) change of provider during the course of treatment for any one accident if the employee requests such change in writing. Fla. Stat. § 440.13 (2) (f). Except for emergency care, the treating provider may not refer the employee to another provider without prior authorization from the insurer. Referrals to specialists are not considered a change in treating provider. Fla. Stat. § 440.13 (3) (c).
Under a Managed Care Arrangement (MCA): An employee subject to a MCA must receive medical services pursuant to the MCA contract as long as the employer and insurer have provided adequate notice to the employee. Any treatment outside the arrangement is not compensable unless preauthorized by the insurer. Fla. Stat. § 440.134 (17).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form. However, Panels with no Initial Care Clinics/Primary Care Physicians listed and/or no Acute Care Hospitals listed must display a message directing the employee to seek medical appropriate care.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR GEORGIA
Overview:
The employee selects the initial provider. Therefore, the Panel Minimum and Maximum rules must be followed and a listing that includes only one (1) provider is not permitted. You must use the Georgia state-specific panel form. The panel should be reviewed every six (6) months to determine whether all of the physicians listed are still valid and doing a good job.
Initial Choice of Provider:
General Rule: The employee selects a provider from a panel "Panel of Physicians" chosen by the employer or insurer. O.C.G.A. § 34-9-201 (b)(1).
Provider Change and Provider Referrals:
General Rule: The employee may make one (1) change from one provider to another on the same panel without authorization of the Board. O.C.G.A. §34-9-201 (b)(1) Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
GA state mandatory form WC-P1 is to be used for panels. Panels must also include the GA Bill of Rights. Legislation requires an orthopedic surgeon on the posted panel; it restricts industrial clinics to two (2). Industrial clinics include urgent care facilities. O.C.G.A. §34-9-201(b)(1) GA Best Practices provides that panels should be reviewed every six (6) months to determine whether all of the physicians listed are still valid and are doing a good job for both the employer and its employees.
Panel Minimum & Maximum Provider Content:
- 6 (1 Orthopedic Surgery and 5 providers, comprised of no more than 2 Occupational Medicine providers (including urgent care facilities) and 3 Primary Care Physicians. The panel must include at least one minority physician where feasible)
- 0 Acute Care Hospitals
- 10 (1 Orthopedic Surgery and 9 providers, comprised of more than 2 Occupational Medicine providers (including urgent care facilities) and 7 Primary Care Physicians)
- 0 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR HAWAII
Overview:
The employee may select any physician for the initial visit. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select any physician or surgeon who is practicing on the island where the injury was incurred. If the services of a specialist are indicated, the employee may select any physician or surgeon practicing in the State. The director may authorize the selection of a specialist practicing outside the State where no comparable medical attendance within the State is available. HRS § 386-21(b).
Provider Change and Provider Referrals:
General Rule: If for any reason during the period when medical care is needed, the employee wishes to change to another physician or surgeon, the employee may do so in accordance with rules prescribed by the director. HRS § 386-21 (b). Per the Disability Compensation Division website, the injured employee may change the attending physician once, but must notify the insurer before making the change. Any other changes require prior approval from the insurer. In addition, the attending physician may refer the employee to other specialist(s) with the approval of the insurer.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR IDAHO
Overview:
In Idaho, the employer selects the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. The employee must petition the commission for a change as indicated below.
Initial Choice of Provider:
General Rule: The employer/insurer can designate a particular provider or provider network for its injured workers (must be disclosed at time of hire and applied uniformly). However, when no provider is designated, the employee chooses the provider. Go to the Idaho Industrial Commission for details: https://iic.idaho.gov/faqs/faqs_injured_worker.html.
Provider Change and Provider Referrals:
General Rule: The employee, upon reasonable grounds, may petition the commission for a change of physician to be provided by the employer; however, the employee must give written notice to the employer or surety of the employee's request for a change of physicians to afford the employer the opportunity to fulfill its obligations under this section. If proper notice is not given, the employer shall not be obligated to pay for the services obtained. Employer must render its written decision on the claimant's request within fourteen (14) days. If any dispute arises, the industrial commission will conduct an expedited hearing to decide the issue of the change of physician. Idaho Code §72-432 (4)(a). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR ILLINOIS
Zenith does not offer a Preferred Provider Program.
Overview:
In Illinois, the employee designates the physician for initial medical treatment. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may choose a provider for initial care either from the employer's posted panel of providers or a provider not included on the employer's panel. 820 ILCS 305/8. First aid and emergency care are not considered an initial choice of provider. Go to the Illinois Workers' Compensation Commission for details: http://www.iwcc.il.gov.
Preferred Provider Program:
Illinois allows use of Preferred Provider Programs (PPP) as set forth in the applicable laws, rules and regulations. See Workers' Compensation Act 820 ILCS 305/8.1(a). Zenith does not currently offer a PPP in Illinois.
Provider Change and Provider Referrals:
General Rule: The employee may elect to change providers one time at the employee's own discretion. A subsequent change of treating provider is subject to employer or insurer approval. Referrals to specialists are not considered a change in treating physician. http://www.iwcc.il.gov.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR INDIANA
Overview:
In Indiana, the employer selects the treating physician. Therefore, the employer may request and post a panel listing that includes only one (1) provider.
Initial Choice of Provider:
General Rule: The employer or insurer chooses the treating provider. The employee may select a treating provider in the event of an emergency or if the employer or insurer fails to provide reasonable and necessary treatment. Burns Ind. Code Ann. § 22-3-3-4.
Provider Change and Provider Referrals:
General Rule: The employee may select a treating provider in the event of an emergency or if the employer or insurer fails to provide reasonable and necessary treatment. Burns Ind. Code Ann. § 22-3-3-4. Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR IOWA
Overview:
In Iowa, the employer selects the initial treating physician. Therefore, one (1) provider may be listed on the panel for initial care. Changes of physician requested by the employee must be brought before a Commissioner.
Initial Choice of Provider:
General Rule: The employer or insurer chooses the treating provider. Emergency treatment must be provided without undue inconvenience to the employee. Iowa Code § 85.27 (4).
Provider Change and Provider Referrals:
General Rule: The employee may request a change in provider with the employer. If the employee and employer cannot agree on alternate care, the Commissioner may, upon application and reasonable proof, allow and order other care. In an emergency, the employee may choose the employee's care at the employer's expense, provided the employer or the employer's agent cannot be reached immediately. Iowa Code § 85.27 (4). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR KANSAS
Overview:
In Kansas, the employer selects the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. If approved and only after approved by the Director, the employer must provide a list to the employee with a minimum number of providers as indicated above.
Initial Choice of Provider:
General Rule: The employer or insurer chooses the treating provider for initial care. K.S.A. § 44-510h (a).
Provider Change and Provider Referrals:
General Rule: The Director may authorize a change of treating providers if the Director finds, upon application by the employee, that the services of the treating provider are unsatisfactory. If the Director authorizes this change, the employer must provide a list of two (2) providers from which the employee will select a new treating provider. If the employee is unable to obtain satisfactory services from any of the health care providers submitted by the employer, either the employee or employer may request the Director select a new treating provider. K.S.A. § 44-510h (b) (1). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 2 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR KENTUCKY
Zenith does not offer a certified managed care plan.
Overview:
In Kentucky, the employee chooses the initial treating physician and you cannot direct injured worker to network provider. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may choose the provider for initial care. KRS § 342.020(4). If the employer has adopted a certified managed care plan, the employee must select a provider from within the certified managed care plan. KRS § 342.020(7)(b). If a certified managed care plan is not used, the injured worker may select any provider that accepts workers' compensation patients and panels and directories are not permitted except for informational purposes.
Provider Change and Provider Referrals:
General Rule: If the employer has chosen to participate in a certified managed care plan, the injured employee chooses a provider from within that network. Referrals to specialists are not considered a change in treating physician. If a certified managed care plan is not used, the injured worker may select any provider that accepts workers' compensation patients.
Panels and Directories:
Panel and Directories are required for employers who have adopted a certified managed care plan. Panels and Directories may be used for informational purposes only outside of a certified managed care plan. There is no state mandated panel form; however, it must be clear to the injured worker that they can select any provider for treatment and are not limited to providers set forth in the informational Panel or Directory.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR LOUISIANA
Overview:
In Louisiana, the employee chooses the initial treating physician.
Initial Choice of Provider:
General Rule: The employee chooses the treating provider without restriction. LA. REV. STAT. ANN. § 23:1121(B)(1).
Provider Change and Provider Referrals:
General Rule: The injured employee may change to a provider in another specialty or field without getting the approval from the employer or insurer. LA. REV. STAT. ANN. § 23:1121(B)(1). The employee must obtain approval from the insurer to change from one provider to another within the same field or specialty. LA. REV. STAT. ANN. § 23:1121(B)(1). Referrals to specialists are not considered a change in treating physician. The physician must have approval from claims administrator to continue treatment beyond $750 worth of care unless the care is provided under emergency conditions. Withholding of consent may not be arbitrary and capricious or without probable cause. RS 23:1142
Panels and Directories:
Panels and directories are not generated for Louisiana since employees may choose their own treating physicians.
WORKERS' COMPENSATION PROVIDER RULES FOR MAINE
Overview:
In Maine, the employer selects the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. If the employee requests a change of physician, as indicated below, he or she must be provided a list with a minimum number of providers indicated below.
Initial Choice of Provider:
General Rule: The employer initially may select a treating health care provider. 39-A M.R.S. § 206(1).
Provider Change and Provider Referrals:
General Rule: The employee may change providers after ten (10) days from the first date of treatment by giving the employer the name of the new provider and a statement of intention to treat with that provider. The employer may file a petition objecting to the named health care provider selected by the employee and setting forth reasons for the objection. 39-A M.R.S. § 206(2). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MARYLAND
Overview:
In Maryland, the employee chooses the initial treating physician. Therefore, the Panel Minimum and Maximum provider rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider.
Provider Change and Provider Referrals:
General Rule: Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MASSACHUSETTS
Overview:
In Massachusetts, the employee chooses the treating physician. Therefore, the Panel Minimum and Maximum provider rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: Except for the employee's first scheduled appointment, which, pursuant to the terms of a preferred provider arrangement entered into under this section, may be required to be with a health care provider within the plan, the employee may select a treating health care professional other than any provided or agreed to by the insurer and may switch to another such professional once. ALM GL ch. 152, § 30.
Provider Change and Provider Referrals:
General Rule: When referred by the treating health care professional to another provider in a particular specialty, the employee may also change once to a different provider in such specialty. In cases of emergency or where the insurer or administrative judge agrees, the employee may seek treatment from additional providers. ALM GL ch. 152, § 30.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 2 Initial Care Clinics/Primary Care Physicians
- 0 Acute Care Hospitals
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MICHIGAN
Overview:
In Michigan, the employer selects the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. After twenty-eight (28) days from the first date of treatment, the employee may select their own provider as indicated below.
Initial Choice of Provider:
General Rule: The employer may select a treating health care provider. MCL § 418.315.
Provider Change and Provider Referrals:
General Rule: The employee may change providers after twenty-eight (28) days from the first date of treatment by giving the employer the name of the new provider and a statement of intention to treat with that provider. The employer may file a petition objecting to the named health care provider selected by the employee and setting forth reasons for the objection. MCL § 418.315. Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MINNESOTA
Zenith does not offer a Managed Care Plan.
Overview:
In Minnesota, the employee selects a treating physician and we cannot direct an injured worker to a network provider. Therefore, the panel minimum and maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider. Go to the Minnesota Department of Labor and Industry for details: http://www.dli.mn.gov.
Under a Managed Care Plan: An employer may require that the treatment and supplies required to be provided by an employer by this section be received in whole or in part from a managed care plan. Minn. Stat. § 176.1351(f).
Provider Change and Provider Referrals:
General Rule: The employee may change providers once within the first sixty (60) days after initiation of medical treatment for the injury without the need for approval from the insurer, the department, or a workers' compensation judge. After the first sixty (60) days following initiation of medical treatment for the injury, any further changes of primary provider must be approved by the insurer, the department, or a workers' compensation judge. Minn. R. 5221.0430.
Referrals to specialists are not considered a change in treating physician.
Under a Managed Care Plan: An employee must be allowed to change health care providers under a managed care plan at least once. Minn. Stat. § 176.1351(11).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MISSISSIPPI
Overview:
In Mississippi, the employer may select a treating provider but it is not mandatory and the employee may select a provider of their own choice. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing with only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employer may select a treating health care provider but that selection is not mandatory for the employee. The employee may accept the employer/insurer recommendation or select a provider of their own choosing. Miss. Code Ann. § 71-3-15(1).
Provider Change and Provider Referrals:
General Rule: Except in an emergency requiring immediate medical attention, any selection of providers by employee after the initial choice of provider must be approved by the insurer. If denied, the employee may apply to the commission to determine whether such request is reasonable. Miss. Code Ann. § 71-3-15(1). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MISSOURI
Overview:
In Missouri, the employer selects the initial treating physician and any changes in providers. Therefore, the employer may request and post a panel listing that includes only one (1) provider.
Initial Choice of Provider:
General Rule: The employer selects a treating provider. The employee may select a provider at the employee's own expense. § 287.140 R.S.Mo.(1).
Provider Change and Provider Referrals:
General Rule: The employer directs care, including change of providers. § 287.140 R.S.Mo. (1). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR MONTANA
Overview:
In Montana, the employee selects the initial treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider. See Workers' Compensation Benefits Summary at www.montanastatefund.com for details.
Provider Change and Provider Referrals:
General Rule: Any time after acceptance of liability by an insurer, the insurer may designate a different treating physician, or approve the employee's choice of the treating physician. 39-71-1101, MCA (2). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEBRASKA
Overview:
In Nebraska, the employee has the right to choose the physician if the employer gives notice of this right following the accident. Employee choice is limited to a physician who has treated them or an immediate family member before the injury. If employee was notified but does not choose, the employer has the right to choose the physician. R.R.S. Neb. § 48-120 Therefore, the panel minimum and maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee has the right to select a physician who has maintained the medical records of the employee (or an immediate family member) when the employer notifies the employee of this right. If the employee does not have or does not choose such a physician, then the employer may select the physician. The employer may have the right to choose an injured employee's primary treating physician. If the employer wishes to choose, the employer must first give the employee notice, following an injury, of the right to choose a family physician as the primary treating physician. R.R.S. Neb. § 48-120
Provider Change and Provider Referrals:
General Rule: If the employee choses the provider or if the employer choses the provider after notifying the employee of the right to choose, the employee may not change providers unless both the employee and the employer agree on the change or the court orders the change. If the employer does not give proper notice to the employee regarding the right of selection, then the restrictions on changing physicians do not apply and the employee has the right to select any physician. The employee also may select a physician to perform a major surgical operation or in cases involving dismemberment Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEVADA
Zenith does not offer a MCO plan.
Overview:
In Nevada, the employee selects the initial medical provider. Therefore, the Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The injured employee selects the initial medical provider. If the insurer has entered into a contract with an organization for managed care ("MCO") or with providers of health care services, the injured employee must select a medical provider per the terms of that contract. The employer shall furnish names, addresses and telephone numbers of two or more physicians or chiropractors who are qualified to conduct the examination and who are available pursuant to the terms of the contract, if there are two or more such physicians or chiropractors within 30 miles of the employee's place of employment. If the insurer has not entered into such a contract, the injured employee must select an authorized medical provider who is a member of the Panel of Treating Physicians and Chiropractor established by the Administrator (the "Panel"). Nev. Rev. Stat. Ann. § 616C.090.
Provider Change and Provider Referrals:
General Rule: If the injured employee is not satisfied with the first medical provider he or she chooses, the injured employee may make an alternative choice from the Panel or pursuant to the terms of a contract with an MCO or providers of health care services (as applicable) if the choice is made within ninety (90) days after his or her injury. Any further change must be made in writing and approved by the insurer. If no action is taken by the insurer within ten (10) days of receipt of such written request, the request is deemed granted. Referrals to specialists are not considered a change in treating physician. Nev. Rev. Stat. Ann. § 616C.090.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEW HAMPSHIRE
Overview:
In New Hampshire, the employee selects the initial medical provider. Therefore, the Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider. RSA 281-A: 23(I).
Provider Change and Provider Referrals:
General Rule: Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEW JERSEY
Overview:
In New Jersey, the employer selects the initial treating provider; therefore, one (1) provider may be listed on the panel for initial care. However, if the employee wishes to change providers, he or she must be provided a list with the minimum number of providers indicated below.
Initial Choice of Provider:
General Rule: The employer may select the initial treating provider. N.J. Stat. § 34:15-15.
Provider Change and Provider Referrals:
General Rule: If the employee requests treatment or services and the employer refuses or neglects to provide treatment or services, the employee may secure such treatment and services as may be necessary. N.J. Stat. § 34:15-15. Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEW MEXICO
Overview:
In New Mexico, the employer shall initially select the health care provider but, since the employee is also permitted to select their own initial health care provider, the Panel Minimum and Maximum rules must be followed at all times.
Initial Choice of Provider:
General Rule: The employer shall initially either select the health care provider for the injured worker or permit the injured worker to make the selection. Subject to the provisions of this section, that selection shall be in effect during the first sixty (60) days from the date the worker receives treatment from the initially selected health care provider. N.M. Stat. Ann. § 52-1-49(B).
From the Workbook for Injured Workers in New Mexico, 2012 Edition: An employer has the right to select the health care provider who will treat the injury first or to allow the employee to select the first HCP. An employer must give instructions in writing to workers about this selection. If the employer did not give the employee an instruction in writing either in advance, or right after the accident, telling the employee to make the first selection, it is presumed that the employer made the first decision.
Provider Change and Provider Referrals:
General Rule: After the expiration of the initial sixty (60) day period set forth in Subsection B of this section, the party who did not make the initial selection may select a health care provider of his choice. Unless the worker and employer otherwise agree, the party seeking such a change shall file a notice of the name and address of his choice of health care provider with the other party at least ten (10) days before treatment from that health care provider begins. N.M. Stat. Ann. § 52-1-49(C). If a party objects to the choice of health care provider made pursuant to Subsection C then he shall file an objection to that choice pursuant to Subsection E of this section with a workers' compensation judge within three (3) days from receiving the notice. N.M. Stat. Ann. § 52-1-49 (D).
If the worker or employer disagrees with the choice of the health care provider of the other party at any time, including the initial sixty (60) day period, and they cannot otherwise agree, then he or she shall submit a request for a change of health care provider to a workers' compensation judge. N.M. Stat. Ann. § 52-1-49 (E).
Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
Maximum:
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NEW YORK
Zenith does not offer a certified PPO product.
Overview:
In New York, the employee selects the initial medical provider. Therefore, the Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The injured employee may select a treating provider who is authorized by the Workers' Compensation Board for any non-emergency treatment. NY CLS Work Comp § 13-a. All employees of an employer who has elected to utilize its workers' compensation insurance carrier's selected preferred provider organization shall obtain initial treatment from such preferred provider organization. 12 NYCRR § 325-8.1.
Provider Change and Provider Referrals:
General Rule: If for any reason during the period when medical treatment and care is required, the employee wishes to transfer his or her treatment and care to another authorized physician, he or she may do so, in accordance with rules prescribed by the chair. 12 NYCRR § 325-8.1. The employer may have the right to transfer care if certain conditions are met. NY CLS Work Comp § 13-a (3). If the employer has elected to utilize a preferred provider organization, any employee may seek treatment from outside of the preferred provider organization thirty (30) days after his or her initial treatment from a preferred provider organization provider. 12 NYCRR § 325-8.1.
Panels and Directories:
We do not access a certified network in this state, therefore, you cannot do panels. You can provide a list of providers to the injured employee for convenience only. State required language must be included with the listing. The Directory Cover sheet includes the required language for New York so be sure to always include the cover sheet with any provider listing.
Panels for the state of New York should not be created unless the employer is enrolled in a certified PPO.
Panel Minimum & Maximum Provider Content:
- 5 Point of Entry providers, preferably Walk-in/Urgent Care Clinics, Occupational Medicine Clinics
- 2 Acute Care Hospitals
- 5 Point of Entry providers, preferably Walk-in/Urgent Care Clinics, Occupational Medicine Clinics
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NORTH CAROLINA
Overview:
In North Carolina, the employer provides the employee a provider listing as indicated below for the employee to select the initial treating provider. Therefore, a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employer may select the initial treating provider. N.C. Gen. Stat. § 97-25.
Provider Change and Provider Referrals:
General Rule: Upon the written request of the employee to the employer, the employer may agree to authorize and pay for a second opinion examination with a duly qualified physician licensed to practice in North Carolina, or licensed in another state if agreed to by the parties or ordered by the Commission. If, within fourteen (14) calendar days of the receipt of the written request, the request is denied or the parties, in good faith, are unable to agree upon a health care provider to perform a second opinion examination, the employee may request that the Industrial Commission order a second opinion examination. The expense thereof shall be borne by the employer upon the same terms and conditions as provided in this section for medical compensation. Provided, however, if the employee so desires, an injured employee may select a health care provider of the employee's own choosing to attend, prescribe, and assume the care and charge of the employee's case subject to the approval of the Industrial Commission. In addition, in case of a controversy arising between the employer and the employee, the Industrial Commission may order necessary treatment. N.C. Gen. Stat. § 97-25. Referrals to specialists are not considered a change in treating provider.
Panels and Directories:
Provider Lists/Panels and directories may be utilized and may be made available to the employer. Form 17 is the state-mandated posting. N.C. Gen. Stat. § 97-93. The employer should give the listing to the injured worker following a work related injury. The listing should include:
- the nearest occupational medical clinic or provider, and
- the nearest urgent care center.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR NORTH DAKOTA
Overview:
North Dakota is a monopolistic state. In North Dakota, the employee chooses an initial treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
The employee chooses the initial physician, however the organization may require the employee's care to be redirected once the injury is determined compensable. N.D. Cent. Code, § 65-05-28.
Provider Change and Provider Referrals:
No employee may change from one (1) doctor to another while under treatment or after being released, without the prior written authorization of the organization. N.D. Cent. Code, § 65-05-28(1).
Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Provider Lists/Panels and directories may not be utilized. There is no state-mandated posting.
Panel Minimum & Maximum Provider Content:
Not Applicable.
WORKERS' COMPENSATION PROVIDER RULES FOR OHIO
Overview:
Ohio is a monopolistic state. In Ohio, the employee chooses their treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
The employee may select a treating health care provider.
Provider Change and Provider Referrals:
An injured worker wishing to change physicians should notify the managed care organization of this request. Go to the Ohio Bureau of Workers' Compensation for details: www.info.bwc.ohio.gov. Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Provider Lists/Panels and directories may be utilized. There is no state-mandated posting requirement. Caution must be exercised by not mandating specific providers. Employers can recommend but not mandate use of medical providers or facilities.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR OKLAHOMA
Zenith does not offer a certified workplace medical plan.
Overview:
In Oklahoma, the employer selects the treating physician because Zenith does not offer a certified workplace medical plan. Therefore, the Panel Minimum and Maximum rules would not apply and a panel listing of only (1) provider would be permitted.
Initial Choice of Provider:
General Rule: Where the employee is not covered by a certified workplace medical plan, the employer shall select the treating physician. 85A O.S. §56(B). (DOES NOT APPLY INFORMATIONAL ONLY: If a certified workplace medical plan was used, the employer would still select a physician from the certified workplace medical plan network.)
If the employer fails or neglects to provide medical treatment within five (5) days after actual knowledge is received of the injury, the injured employee may select a physician to provide medical treatment at the expense of the employer. 85A O.S. § 50(B).
Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR OREGON
Zenith does not offer a MCO plan.
Overview:
In Oregon, the employee may choose the initial treating physician and up to two (2) treating physicians thereafter without approval of the Director of the Department of Consumer and Business Services (Director).
Initial Choice of Provider:
General Rule: The worker may choose an attending doctor, physician, or nurse practitioner within the State of Oregon. ORS § 656.245(2)(a). No one may require a worker injured on the job to obtain treatment from a specific provider or type of provider. Oregon Industry Notice November 14, 2011. See https://wcd.oregon.gov/IndustryNotices/11-14-11-IN-HB2093.pdf Referrals to specialists are not considered a change in treating physician.
Provider Change and Provider Referrals:
General Rule: The worker may choose the initial attending physician or nurse practitioner and may subsequently change attending physician or nurse practitioner two (2) times without approval from the Director. If the worker thereafter selects another attending physician or nurse practitioner, the insurer or self-insured employer may require the Director's approval of the selection. The decision of the Director is subject to review under ORS § 656.704. The worker also may choose an attending doctor or physician in another country or in any state or territory or possession of the United States with the prior approval of the insurer or self-insured employer. ORS § 656.245(2)(a).
Panels and Directories:
Provider Lists/Panels and directories may be utilized. For an MCO, there is a state-mandated posting, which is distributed by the Managed Care partner. Panels must include a minimum of one attending physician for every 1,000 workers covered. If no MCO exists, then no posting is permitted.
WORKERS' COMPENSATION PROVIDER RULES FOR PENNSYLVANIA
Overview:
In Pennsylvania, the employee may select their own initial treating provider. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted. There is a state-mandated posting (Panel).
Initial Choice of Provider:
General Rule: The employee may select the initial treating provider. 77 P.S. § 531(1) (i).
Under an Employer Established List of Designated Health Care Providers ("Provider List"): The employee must select a provider from the Provider List. 77 P.S. § 531(1) (i).
Provider Change and Provider Referrals:
General Rule: The employee may select any medical provider. 77 P.S. § 531(1) (i).
Under an Employer Established List of Designated Health Care Providers ("Provider List"): The employee must select and treat with a provider from the Provider List for ninety (90) days following the date of first treatment. If invasive surgery is recommended, the employee may receive an additional opinion from any health care provider. If the injured worker chooses to follow the procedures designated by the second opinion, such procedures must be performed by a provider on the Provider List for a period of ninety (90) days from the date of the first visit to that provider. 77 P.S. § 531(1) (i).
Panels and Directories:
Panels and Directories are allowed. There is a state-mandated posting (Panel). The panel must include at least six (6) designated providers. No more than four (4) may be coordinated care organizations (CCO), and no fewer than three (3) must be physicians. 77 P.S. § 531(1) (i).
Panel Minimum & Maximum Provider Content:
- A minimum of 6 providers: 2 Initial Care Clinics or Primary Care Physicians, at least 1 per specialty for Orthopedic Surgery and Physical Therapy - but no more than 2; and no more than 1 per specialty of Physical Medicine & Rehabilitation, Neurology, Neurosurgery (Surgery: Neurosurgery), Ophthalmology, Hand Surgery, General Surgery, Chiropractic Medicine, or Sports Medicine.
- 0 Acute Care Hospitals
- A maximum of 11 providers: 2 Initial Care Clinics or Primary Care Physicians, at least 1 per specialty for Orthopedic Surgery and Physical Therapy - but no more than 2; And no more than 1 per specialty of Physical Medicine & Rehabilitation, Neurology, Neurosurgery (Surgery: Neurosurgery), Ophthalmology, Hand Surgery, General Surgery, Chiropractic Medicine, or Sports Medicine.
- 1 Acute Care Hospital
WORKERS' COMPENSATION PROVIDER RULES FOR RHODE ISLAND
Overview:
In Rhode Island, the employee may select the treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and listings with only one (1) provider are not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider. R.I. Gen. Laws § 28 33-8 (a) (1).
Provider Change and Provider Referrals:
General Rule: Referrals to specialists are not considered a change in treating physician. If the insurer has a preferred provider network approved and kept on record by the medical advisory board, any change by the employee from the initial health care provider of record shall only be to a health care provider listed in the approved preferred provider network. Otherwise, the employee must obtain approval from the insurer. R.I. Gen. Laws § 28 33-8 (a) (1).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 2 Initial Care Clinics/Primary Care Physicians
- 0 Acute Care Hospitals
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR SOUTH CAROLINA
Overview:
In South Carolina, the employer may select the initial treating provider; therefore, one (1) provider may be listed on the panel for initial care. Any change in provider requires the employer's approval. If such approval is given, the employee should be provided a list with a minimum number of providers indicated above.
Initial Choice of Provider:
General Rule: The employer may select a treating health care provider. S.C. Code Ann. § 42-15-60 (A).
Provider Change and Provider Referrals:
General Rule: Change in treating provider requires employer or insurer approval or the employee may request a hearing with the Commissioner to make a determination. S.C. Code Ann. § 42-15-60. Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR SOUTH DAKOTA
Zenith does not offer a managed care plan.
Overview:
In South Dakota, initially the employee selects the initial treating physician. However, managed care plans are mandatory. S.D. Codified Laws § 58-20-24. Employees may still elect to seek initial treatment outside of the plan, but the physician selected by the employee must stay within the managed care plan for any subsequent medical referrals. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may make the initial selection of the employee's medical practitioner or surgeon from among all licensed medical practitioners or surgeons in the state. The employee shall, prior to treatment, notify the employer of the choice of medical practitioner or surgeon or as soon as reasonably possible after treatment has been provided. S.D. Codified Laws § 62-4-43.
Provider Change and Provider Referrals:
General Rule: If the employee desires to change the employee's choice of medical practitioner or surgeon, the employee shall obtain approval in writing from the employer. An employee may seek a second opinion without the employer's approval at the employee's expense. Referrals to specialists are not considered a change in treating physician. S.D. Codified Laws § 62-4-43.
Panels and Directories:
Panels and Directories may be utilized. However, all workers' compensation insurers must participate in a Managed Care Plan and must include case management and utilization review services. There is a state-mandated posting (Panel), which is distributed by the Managed Care Plan partner.
Panel Minimum & Maximum Provider Content:
- 1 Initial Care Clinic/Primary Care Physician
- 1 Acute Care Hospital
- 4 Initial Care Clinic/Primary Care Physician
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR TENNESSEE
Overview:
In Tennessee, the employee selects the initial provider from a panel which must have a minimum of three (3) providers as indicated below. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted. The state-mandated posting (Panel) - Form C-42 must be used.
Initial Choice of Provider:
General Rule: The employee chooses the treating provider from a panel developed by the employer/insurer (see below for requirements). Tenn. Code Ann. § 50-6-204(a) (3).
Provider Change and Provider Referrals:
General Rule: Referrals to a specialist physician, surgeon, chiropractor, or specialty practice group are considered a change in treating provider until such time that the injured employee is referred back to the original treating provider. Tenn. Code Ann. § 50-6-204(a) (3) (E). The original treating provider must immediately notify the employer of the referral. If the employer does not provide the employee a panel of at least three (3) independent reputable physicians, surgeons, chiropractors, or specialty practice groups within three (3) business days, the employer will be deemed to have accepted the referral. The employee must select from the panel if the employer does provide such panel within three (3) business days. Tenn. Code Ann. § 50-6-204(a) (3) (A) (ii)
Panels and Directories:
Panels and Directories are allowed. There is a state-mandated posting (Panel) - Form C-42. The panel must include three (3) or more independent reputable providers (see below for requirements). If the employee does not sign and return the form to the employer, any treatment by the employee with a provider on the panel shall constitute acceptance of the panel and selection of the provider as treating provider. Tenn. Code Ann. § 50-6-204(a) (3) (D) (ii).
Panel Minimum & Maximum Provider Content:
- Three (3) independent reputable physicians, surgeons, chiropractors, or specialty practice groups if available in the injured employee's community. Tenn. Code Ann. § 50-6-204(a) (3) (A).
- If three (3) providers are not available in the employee's community, the employer must provide a list of three (3) independent reputable physicians, surgeons, chiropractors, or specialty practice groups from at least two (2) separate medical groups within 125 miles of the injured employee's community. Tenn. Code Ann. § 50-6-204(a) (3) (B).
- If the employee changes his/her community of residence, the employer must provide the employee a new panel of reputable physicians, surgeons, chiropractors, or specialty practice groups in the employee's community. Tenn. Code Ann. § 50-6-204(a) (3) (F).
- If any panel provider declines to treat the employee, the employee may select a provider from the remaining list or request another provider be added to the list. Tenn. Code Ann. § 50-6-204(a) (3) (G).
- When a treating physician or chiropractor refers the employee, the employee is entitled to a second opinion on the issue of surgery and diagnosis from a physician or chiropractor specified in the initial panel. A second opinion does not change the previous selection of treating physician or chiropractor. Tenn. Code Ann. § 50-6-204(a) (4) (C).
- One (1) Acute Care Hospital
- Five (5) independent reputable physicians, surgeons, chiropractors, or specialty practice groups
- Two (2) Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR TEXAS
Panels are not permitted in Texas.
Provider listings may be provided per rules below.
Overview:
Panels are not permitted in the State of Texas; therefore, the rules indicated must be followed at all times and a listing that includes only one (1) provider is not permitted.
Zenith offers two (2) products in Texas, an HCN product and a non-HCN. The employer chooses which option they will use. Different rules are applicable as noted below.
For the HCN product, Zenith manages the Zenith HealthCare Network (ZHCN) which is available in 231 Texas counties. The ZHCN represents a subset of the Coventry and First Health health care provider networks in Texas. Provider listings can be generated (please see the information below regarding panels and directories in Texas).
HCN Employee Notification Requirements:
An injured employee is not required to comply with the HCN requirements until the employee receives notice of the HCN. Tex. Ins. Code § 1305.005 (h).HCN notice must be given to the employee at the time of enrollment and at the time the employer receives notice of an injury. Tex. Ins. Code § 1305.005 (g). New employees must receive these documents within three (3) days of hire. Tex. Ins. Code § 1305.005 (e).
Additionally, the employer must obtain a signed acknowledgment from each employee and post notice of the HCN requirements at each place of employment. An employee who received notice but refuses to sign the acknowledgment is still subject to the HCN. Tex. Ins. Code §§ 1305.005 (d) (1) (2), 1305.005 (f).
Initial Choice of Provider:
Employees Subject to a Health Care Network (HCN): Unless an employee has pre-designated a non-HCN provider or requires emergency medical attention, the employee must select a provider from the list of HCN providers that provides services within the service area in which the employee lives ("Service Area"). Tex. Ins. Code §§ 1305.104(a), 1305.006.
Employees Not Subject to an HCN: An employee may select the initial treating provider, but such selection must be from a list of providers approved by the Commissioner. Tex. Lab. Code § 408.022(a).
Provider Change and Provider Referrals:
Employees Subject to a Health Care Network (HCN): An employee may select an alternate treating physician from the HCN's list of treating providers who provide services within the Service Area by notifying the HCN in the manner prescribed by the HCN. The HCN may not deny a selection of an alternate treating doctor. Tex. Ins. Code § 1305.104(b). In the event of an emergency, the employee may choose a non-HCN provider, but must transfer to an HCN provider upon discharge. Tex. Ins. Code §1305.104 (a) (2).
Employees Not Subject to an HCN: An employee may change providers if the employee notifies the division and requests authority to select an alternate provider. Tex. Lab. Code § 408.022 (b).
Panels and Directories:
- Employees Subject to a Health Care Network (HCN): Panels are not permitted in Texas. Should a request be received for a listing or directory, it must be clear that the list or directory is only intended to be a convenience tool to assist employees with workers' compensation claims in obtaining medical care from ZHCN providers. Employees are not limited to the healthcare providers in the listing or directory and have access to the entire ZHCN to choose an initial and alternate treating provider. The provider listing or directory should be comprised of 2-5 verified Primary Treating Providers and one hospital.
- Employees Not Subject to an HCN: Panels and Directories are not permitted in Texas and should not be provided to employees not subject to an HCN. Should a request be received for a listing, the listing must be clear that the directory should ONLY be provided to the employee as a convenience tool. The listing must include the following disclosure: "This listing is for convenience purposes only. You have a choice of providers beyond this listing."
WORKERS' COMPENSATION PROVIDER RULES FOR UTAH
Overview:
In Utah, the employee may select his or her own initial treating physician unless a company doctor, designated provider, or PPO is named. Utah Code Ann. § 34A-2-111 (2) (b) (ii) (B) Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: If a company doctor, designated facility or PPO is named, the employee must first treat with that designated provider. Utah Code Ann. § 34A-2-111 (2) (b) (ii) (A) (I)
A preferred provider program must allow an injured worker to select from two or more providers to obtain necessary medical care. U.A.C. R612-300-2 A. (2). If no such doctor, facility or PPO has been designated, the employee may obtain initial medical treatment from a provider of the employee's choice. Utah Labor Commission Employees Guide to WC2016-2017.
Provider Change and Provider Referrals:
General Rule: The employee may make one (1) change of doctor without requesting the permission of the carrier, so long as the carrier is promptly notified of the change by the employee. Referrals to specialists are not considered a change in treating physician. U.A.C. R612-300-2 D. (1).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 1 Initial Care Clinic/Primary Care Physician
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR VERMONT
Overview:
In Vermont, the employer may select the initial treating physician; therefore, one (1) provider may be listed on the panel for initial care. After initial treatment, the employee may change providers and he or she should be provided a list with a minimum number of providers indicated above.
Initial Choice of Provider:
General Rule: The employer may select a treating health care provider. 21 V.S.A. § 640(b).
Provider Change and Provider Referrals:
General Rule: After the initial treatment, the employee may select another health care provider upon giving the employer written notice of the employee's reasons for dissatisfaction with the health care provider designated by the employer and the name and address of the health care provider selected by the employee. 21 V.S.A. § 640(b). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR VIRGINIA
Overview:
In Virginia, the employee selects the initial treating physician from a list of a minimum of three (3) physicians selected by the employer. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing that includes only one (1) provider is not permitted. There is no state specified panel (VA does have a state specified poster, VWC1).
Initial Choice of Provider:
General Rule: The employee selects a treating provider from a panel of three (3) physicians selected by the employer. Va. Code Ann. § 65.2-603(A) (1). The panel must include physician names and such physicians must be located within a reasonable distance from the employee's residence. Additionally, the Virginia Workers' Compensation Commission clarifies that the physicians on the panel must not be in the same practice group and must not otherwise share a community of interest (e.g., belonging to a joint practice).
Provider Change and Provider Referrals:
General Rule: The employer may request the Commission order a change of providers based on the grounds listed in Allen & Rocks, Inc. v. Briggs (e.g., inadequate treatment is being rendered; it appears that treatment is needed by a specialist in a particular field and is not being provided; no progress is being made in the improvement of the employee's health condition without any adequate explanation; conventional modalities of treatment are not being used; no plan of treatment of long-term disability cases and failure to cooperate with discovery proceedings ordered by the commission). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form. The panel is not intended to be posted at the workplace site. Rather, the panel must be provided to the employee as soon as reasonably possible after a work related injury occurs. The panel should include physician names that are located within a reasonable distance from the employee's residence and not share a community of interest in a joint practice.
Panel Minimum & Maximum Provider Content:
- 3 Primary Care Physicians
- 1 Acute Care Hospital
- 4 Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR WASHINGTON
Overview:
Washington is a monopolistic state.
Initial Choice of Provider:
Washington is an exclusive state fund state.
Provider Change and Provider Referrals:
Not applicable.
Panels and Directories:
Provider Lists/Panels and directories may be utilized. There is no state-mandated posting. No postings are permitted.
Panel Minimum & Maximum Provider Content is not governed by law, but to be utilized as a suggestion only:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR WEST VIRGINIA
Zenith does not offer a managed care plan.
Overview:
In West Virginia, the employee may select an initial treating physician. Therefore, the Panel Minimum and Maximum rules must be followed at all times and a listing with only one (1) provider is not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating health care provider. W. Va. Code § 23-4-3(b) (2).
Under a Managed Health Care Plan: If the employer has a managed health care plan or program; the employee must select a provider through the managed health care plan. W. Va. CSR § 85-21-4(4.1).
Provider Change and Provider Referrals:
General Rule: Under W. Va. Code § 23-4-3(b)(2), an employer can choose to participate in a managed health care plan, including a preferred provider organization or health maintenance organization or managed care organization or other cost containment relationship. If the employer does not provide a management health care plan or program, the injured employee may select his or her initial health care provider for treatment of a compensable injury unless the commission has established a program and requires the injured employee to select a provider from the commissions program. If a claimant wishes to change his or her health care provider and if his or her employer has established and maintains a managed health care plan, the claimant shall select a new health care provider through the managed health care plan. A claimant who has used the providers under the employer's managed health care plan may select a health care provider outside the employer's plan for treatment of the compensable injury or disease if the employee receives written approval from the commission to do so and the approval is given pursuant to criteria established by rule of the commission.
Under a Managed Health Care Plan: If the employer has established and maintains a managed health care plan, the claimant must select a new provider through the managed health care plan. W. Va. Code § 23-4-3(b) (2). Referrals to specialists are not considered a change in treating physician.
If an employee seeks to change his or her initial choice of health care provider where neither the employer nor the Workers' Compensation Commission had an approved health care management plan at the time the initial choice was made, and if the employee's employer does not provide access to such a plan as part of the employer's general health insurance benefit, then the employee will be provided with a new health care provider from the Workers' Compensation Commission's managed health care plan available to him or her. W. Va. Code § 23-4-3(b) (3) (B).
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR WISCONSIN
Overview:
In Wisconsin, we cannot direct care to an injured worker and the employee selects their initial treating physician. Therefore, the Panel Minimum & Maximum rules must be followed at all times and listings that include only a single provider are not permitted.
Initial Choice of Provider:
General Rule: The employee may select a treating provider. Wis. Stat. § 102.42 (2) (a).
Provider Change and Provider Referrals:
General Rule: The employee has the right to a second choice of provider on notice to the employer or insurer. Any further choice shall be by mutual agreement. Wis. Stat. § 102.42 (2) (a). Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Panels and Directories are allowed. There is no state-mandated panel form.
Panel Minimum & Maximum Provider Content:
- 3 Initial Care Clinics/Primary Care Physicians
- 1 Acute Care Hospital
- 4 Initial Care Clinics/Primary Care Physicians
- 2 Acute Care Hospitals
WORKERS' COMPENSATION PROVIDER RULES FOR WYOMING
Overview:
Wyoming is a monopolistic state.
Initial Choice of Provider:
An employer or the division may designate health care providers to provide nonemergency medical attention to his employees; however, the employee may for any reason, select any other health care provider. If the employee selects a health care provider other than the one selected by the employer or the division, the employer or division may require a second opinion from a health care provider of their choice. Wyo. Stat. § 27-14-401 (f).
Provider Change and Provider Referrals:
Referrals to specialists are not considered a change in treating physician.
Panels and Directories:
Not applicable
Panel Minimum & Maximum Provider Content:
Not applicable