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Nebraska Workers' Compensation Legal Library


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RULE 57
MANAGED CARE
REPORTING REQUIREMENTS
A. Contracts. A managed care plan shall provide the court with copies of the following
contracts:
1. Contracts between the managed care plan and any insurer, risk management pool, or self-insured employer, signed by the parties, within 30 days of execution of such contracts. Such contracts must include a listing of all employers covered by each contract, including the employer's name, address, telephone number, unemployment insurance identification number, and estimated number of employees and location of the employees covered by the managed care plan contract.
2. Contracts between the managed care plan and any entity other than health care providers that perform any of the functions of the managed care plan, which have not previously been provided with the application for certification. These must be signed by the parties and submitted within 30 days of execution of such contracts.
3. New standard contracts between the managed care plan and health care providers who will deliver services under the plan, if such contracts have not previously been provided with the application for certification. These must be submitted within 30 days of adoption. Such new contracts must meet the requirements set out in Rule 52,A,3.
B. Amendments; Changes. Within 30 days of execution or adoption, a managed care plan shall provide to the court the following amendments or changes. 1. Amendments to any of the contracts listed in Rule 57,A as well as amendments to any contracts previously provided with the application for certification.
2. Changes in the managed care plan's ownership or organizational status, or the affiliation of the managed care plan with an insurer, risk management pool, or employer other than through a contract to provide management of treatment for injuries and diseases compensable under the Nebraska Workers' Compensation Act.
3. Any other amendments to the certified managed care plan.

C. Annual reporting. In order to maintain certification, each managed care plan shall, with a nonrefundable fee of $400, provide to the court within 30 days following each anniversary of certification the following information:
1. A current listing of participating health care providers, including names, clinics, addresses, telephone numbers, types of license, certification or registration,and specialties. The managed care plan must also submit a statement that all licensing, certification or registration requirements for the providers are current and in good standing in Nebraska or the state in which the provider is practicing.
2. A summary of any sanctions or punitive actions taken by the managed care plan against any of its participating providers.
3. A summary of any peer review, utilization review, reported complaints and dispute resolution proceedings showing cases reviewed, issues involved, and action taken.
4. Any other information requested by the court.
D. Data, Requested or Required. The managed care plan must report to the insurer, risk management pool, or self-insured employer any data regarding medical, surgical, and hospital services related to a workers' compensation claim requested by the insurer, risk management pool, or self-insured employer to determine compensability under the Nebraska Workers' Compensation Act and any other data required by statute or rule.
E. Monitoring. The court may monitor and conduct periodic audits and special examinations of the managed care plan as necessary to ensure compliance with the managed care plan certification and performance requirements. All records of the managed care plan and its participating health care providers relevant to determining compliance with Rule 51 through Rule 61, and sections 48-120 and 48-120.02, shall be disclosed within a reasonable time after request by the manner unless a legend is provided for the codes.
Sections48-120.02, RRS. 2010, and48-120, RS. Supp., 2016.
Effective date: July 1, 1997.



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