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24.29.2303    DEFINITIONS

The following definitions apply to this subchapter:

(1) "Applicant" means an individual, partnership, corporation or other legal entity seeking original certification as a MCO.

(2) "Certification" means authorization from the department to provide managed care services pursuant to the provisions of the Workers' Compensation Act.

(3) "Community" means the area within a 30 mile radius of the injured worker's residence, if there is a MCO (which has contracted with the injured workers' insurer) within that area.

(4) "Department" means the department of labor and industry.

(5) "Dispute" means a written complaint about how the MCO provides services to the injured worker or about a decision the MCO has made that affects the injured worker. A complaint that is not written is not a dispute within the meaning of these rules.

(6) "Injured worker" means a person who has suffered an occupational injury or disease for which an insurer:

(a) has accepted liability pursuant to the terms of the Workers' Compensation or Occupational Disease Acts; or

(b) is making compensation payments to the worker pursuant to 39-71-608 , MCA, or any other reservation of rights, and the insurer agrees to pay for all of the services provided by the MCO to that injured person.

(7) "Member" means an individual health care provider, (including, but not limited to a physician, osteopath, chiropractor, dentist, physician assistant, podiatrist, optometrist, physical therapist or occupational therapist) other than a personal doctor, who regularly provides services for or on behalf of a MCO, whether as an employee of the MCO or pursuant to contract. Ancillary personnel providing service, but who do not have direct responsibility for management of an injured worker's care are not included in this definition.

(8) "Miles" means air miles ("as the crow flies") from the point referenced, without regard to the availability of a convenient or direct roadway.

(9) "MCO" means a managed care organization that is certified under these rules.

(10) "Personal doctor" means a person who:

(a) is qualified to be a treating physician;

(b) has a documented history of providing treatment to the injured worker prior to the injury, for any condition;

(c) maintains the injured worker's medical records; and

(d) is one of the following types of practitioners:

(i) family practitioner;

(ii) general practitioner;

(iii) internal medicine practitioner; or

(iv) chiropractor.

(11) "Plan" means the written statement that details how a managed care organization will deliver medical and other services to claimants and insurers, unless the context clearly indicates otherwise.

(12) "Primary medical services" has the same meaning as provided by section 39-71-116 , MCA.

(13) "Secondary medical services" has the same meaning as provided by section 39-71-116 , MCA.

(14) "Service contract" means an agreement between an insurer and a MCO whereby the insurer may direct claimants to the MCO for medical and other services.

(15) "Treating physician" has the same meaning as provided by section 39-71-116 , MCA.

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.

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