04 NCAC 10D .0106          CONTRACT PROVISIONS

An MCO's contract with an employer subject to the Rules in this Subchapter shall include:

(1)           the principal place(s) of employment of the covered employees, including address(es) and phone number(s) of the workplace(s);

(2)           the name, title, mailing address, phone number, fax number, and email address, if any, of an officer or responsible employee of the MCO empowered to assent to the treatment or referral of covered employees, capable of obtaining and providing complete business, administrative and medical records generated pursuant to the contract, and empowered to resolve routine disputes with employees, employers and providers under the Commission's jurisdiction;

(3)           the name, title, mailing address, phone number, fax number, and email address, if any, of an adjuster, officer, agent or employee of the employer empowered to negotiate the resolution of routine medical compensation disputes, and receive orders of the Commission on behalf of the employer;

(4)           an acknowledgment that the MCO is bound by applicable requirements of Chapters 58 and 97 of the North Carolina General Statutes and the rules in this Subchapter, and is subject to orders of the Commission to the same extent as the employer;

(5)           the agreement of the employer that it will cooperate and assist in furnishing its employees and supervisors with a phone number and instructions for obtaining emergency treatment and contacting the MCO upon injury to any employee during the workday or on the employer's premises requiring physician attention;

(6)           a dispute resolution plan in accordance with G.S. 97-25.2, including provisions for notice of decision in appeals within 30 days, or within 72 hours of appeal when the regular appeals process would cause a delay in the rendering of health care that would be detrimental to the health of the employee;

(7)           a description of physician panels, including specialties represented, and the employee's right to select his or her attending physician from the appropriate panel, and to subsequently change attending physicians once within the members of the panel; and

(8)           whether the MCO or employer will be responsible for securing the services of "out of network" providers when needed.

 

History Note:        Authority G.S. 97-25.2;

Eff. January 1, 1996;

Amended Eff. July 1, 2014.