FAQ
Q: What is Montana Health Systems?
A: MHS is a state-certified managed care organization. We contract with physicians, hospitals, and other health care providers to provide medical services to covered employees with work-related injuries or illnesses. Our providers are carefully selected and trained in the treatment of work-related conditions. MHS, and the health care providers in our network, want to make sure that timely, effective, and convenient medical services are available for our covered workers. MHS will also be working closely with your doctor and insurer to help you return to gainful employment as soon as possible after an on-the-job injury or illness.
Q: Is MHS a Workers' Compensation insurance company?
A: No. MHS contracts with insurance companies and self-insured employers to provide managed care services to injured workers. We monitor medical care that is provided to ensure that it is appropriate and necessary, and that it meets our quality standards.
MHS does not make decisions on acceptance or denial of claims, payment of time loss or medical benefits, or any other workers' compensation benefits. Decisions concerning these and all other claims issues remain the responsibility of the claims examiner for the insurer or self-insured employer.
Q: Am I required to see one of the MHS doctors if I am injured on the job and need medical care?
A: In most cases, yes. Once your claim is enrolled by your workers' compensation insurance carrier (which means you have been given written notice of your requirement to treat within the MCO) you will be required to treat with an MCO provider unless one of the circumstances explained below applies. However, if you are enrolled in the MCO prior to your claim being accepted, your workers' compensation insurance company will be required to pay for all reasonable and necessary medical services related to your claim received from an MCO member provider that are not otherwise covered by your group health insurance. This requirement applies even if your claim is denied, until you receive notice of the denial, or until three days after the denial is mailed, whichever occurs first. The situations in which you may receive compensable care from a non-MHS provider after your claim is enrolled follow.
1. You have a private physician or nurse practitioner who qualifies as a primary care physician or authorized nurse practitioner.
Your family physician or authorized nurse practitioner may qualify to treat you under the managed care arrangement, even if he or she is not on the MHS list of contracted providers. To qualify:
Your provider must be a medical doctor (M.D.) or osteopath (D.O.) or authorized nurse practitioner.
Your doctor must be a family practitioner, general practitioner, internal medicine specialist or authorized nurse practitioner.
You must have a history of being treated by that doctor or authorized nurse practitioner, or have the doctor or authorized nurse practitioner as a designated primary care provider under your group health plan.
The doctor or authorized nurse practitioner must agree to abide by all terms and conditions of Montana Health Systems, and must refer you to an MHS provider for any additional care you may need.
If your authorized nurse practitioner is qualified to provide your care, he or she will be allowed to authorize time loss for 60 days from the date of the first nurse practitioner visit on the initial claim and may provide medical treatment for 90 days from the date of the first nurse practitioner visit on the initial claim.
2. There are fewer than three MCO providers available in a given category in MHS's geographical service area.
You may be allowed to seek treatment from a non-MHS provider if there are fewer than three MHS providers in the following categories:
•Acupuncturist (L.A.C.)
•Optometrist (O.D.)
•Chiropractor (D.C.)
•Dentist (D.M.D. or D.D.S.)
•Naturopath (N.D.)
•Osteopath ((D.O.)
•Physician (M.D.)
•Podiatrist (D.P.M.)
•Physical therapist
•Psychologist
•Authorized nurse practitioner
All out-of-panel treatment will be subject to MHS's utilization and treatment standards.
3. You reside outside MHS's geographical service area.
If you reside outside MHS's geographical service area you may select a non-MCO provider if they practice closer to your residence than an MCO provider of the same category and if they agree to the terms and conditions of the MCO.
If you think you qualify for any of the above exceptions and would like consideration for out-of-panel treatment, please contact Montana Health Systems.
Should you receive care from a provider who does not meet the above criteria for out-of-panel treatment, your Workers' Compensation insurer will not be required to pay for medical services. In addition, the provider will not be allowed to authorize your time loss from work.
A list of MHS providers in your geographical service area will be provided to you at the time you have a work-related injury or illness that is subject to the MCO agreement. You may also obtain a complete panel list for the entire state by contacting MHS. back to top
Q: What if I live a long distance from MHS's service area?
A: If you live more than one hundred miles from MHS's geographic service area, you will not be subject to the MCO arrangement.
Q: What if I am currently receiving care from a non-MCO provider for a work-related injury or illness at the time I am enrolled into the MCO program?
A: You will be required to treat with an MCO provider, with the exceptions noted above. However, if you have not yet been declared medically stationary, are required to change physicians, and the MCO determines that it would be medically detrimental for you to change physicians, you would not be subject to the MCO requirements until you become medically stationary or choose to change physicians, whichever occurs first.
If you are not yet medically stationary and think that a change of physicians would be medically detrimental to you, you may request review of your situation by the MCO. To request review, please submit your request in writing to the address listed within 30 days of the date of the action. Failure to request review in writing within 30 days precludes further appeal.
Q: What do I do if there is a medical emergency and I'm not able to see an MHS provider?
A: In true emergency cases, MHS, your employer and your insurer believe the first priority is to have the medical emergency taken care of and the worker removed from immediate danger. An emergency is defined as a medical condition that if treatment is not rendered immediately, creates the risk of death, serious disability or serious medical consequences.
If your claim is subject to the MCO, and you are far away from or otherwise unable to receive care from an MHS provider in an emergency, you should seek care from the nearest appropriate medical facility. After you are out of immediate danger, all follow-up care will be provided within the MCO. If emergency care is needed and an appropriate MHS facility is available, care should be sought from the MHS member facility if possible.
If you are in need of emergency care and unsure of where to go, seek medical care from the closest available medical facility. Emergency care should not be used as a substitute for routine, ongoing medical care from an attending physician.
Q: What about medical care I might need for non-work related conditions?
A: MHS has no involvement with medical care that you might seek for illnesses or injuries that are not job-related. You will continue to receive group health benefits, if any, as provided by your employer. Contact your Human Resources or Employee Benefits department for information concerning these benefits.
Q: What do I do if I am injured on the job?
A: Report all injuries to your designated employer representative immediately. He or she will provide you with necessary forms to complete.
Once your claim is enrolled in the MCO, if you require medical care, you may choose to see any physician on the MHS Provider list who is listed as an 'Attending Physician', or an Authorized Nurse Practitioner listed under Non-Attending Physicians. Authorized Nurse Practitioners will be allowed to authorize time loss for 60 days from the date of the first nurse practitioner visit on the initial claim and may provide medical treatment for 90 days from the date of the first nurse practitioner visit on the initial claim. Or, you may treat with a non-MHS provider as explained previously.
If you have trouble scheduling an appointment or need help in accessing care, MHS will be happy to assist you.
In addition, you should always follow all of your company's rules relating to work-related injuries including reporting requirements, modified work schedules, etc.
Q: What can I do if I disagree with an action taken by MHS or its member physicians?
A: All disputes or requests for review regarding actions taken by MHS must first be reviewed through the MHS internal dispute resolution process, as follows:
Any injured worker, medical provider, or employer/insurer having a dispute or request for review arising from the actions of MHS or its representatives may direct such issues to the MHS Administrator. All such requests must be made in writing, and must be made within 30 days of the action giving rise to the complaint. All requests should include an explanation of the issue or decision being disputed, and should include all additional medical evidence the requesting party believes should be included in MHS's review.
All disputes will be reviewed and responded to within 15 days of receipt of all information necessary to issue a decision.
If a dispute cannot be satisfactorily resolved through MHS's internal dispute resolution process, the party requesting review may appeal to the Montana Department of Labor and Industries.