(1) For the purposes of this rule:

(a) "Suspension" means a temporary limitation that prohibits a MCO from either:

(i) entering into new service contracts; or

(ii) accepting additional injured workers to be treated under existing service contracts.

(b) "Revocation" means an involuntary termination of a MCO's certification to provide services under these rules.

(2) The certification of a MCO issued by the department may be suspended or revoked by the department if:

(a) services to injured workers are not being provided in accordance with the provisions of the certified plan;

(b) the plan for providing medical services fails to meet the requirements of these rules;

(c) the MCO fails to comply with applicable rules and statutes;

(d) the MCO submits false or misleading information to the department, insurers, claimants or others;

(e) the MCO knowingly utilizes the services of a health care provider whose license has been revoked or suspended by the licensing board;

(f) the MCO is or was formed by an insurer, or self-insured employer other than a health care provider or medical services provider; or

(g) the MCO fails to timely file reports.

(3) The department will give 20 days written notice to the MCO, and insurers with which the MCO has contracted, of the department's intent to suspend or revoke the certification of the MCO. The notice will specify the grounds for revocation or suspension. If the MCO does not either come into compliance or request a contested case hearing, within 20 days of the notice being sent, the department will suspend or revoke the MCO's certification.

(4) A suspension may be set aside prior to the end of the suspension period if the department is satisfied the MCO has remedied the condition which led to the suspension.

(5) If the certification of a MCO is revoked and the MCO wishes to again apply for certification, it must go through the entire application process (including payment of the application fee) before it can be certified.

History: Sec. 39-71-203, 39-71-1103 and 39-71-1105 MCA; IMP, Sec. 39-71-1103 and 39-71-1105 MCA; NEW, 1994 MAR p. 420, Eff. 3/1/94.