CMP.6.5.010 Medical Care, Benefits and Examination of Claims
(a) Medical Care
(1) A licensed professional Health Care Provider must provide medical care. The treating medical doctor is referred to as the primary physician. The primary physician can only make referral to a chiropractor or another physician, such as a specialist, and approval must be sought from the Claims Administrator/Managed Care Provider. The Employee may not change primary physicians or seek treatment from another referral physician without the approval of the Employer and the Claims Administrator/Managed Care Provider. Only medical expenses ordered by the primary physician or the approved referral physician are payable under the Plan.
(2) The primary physician or approved referral physician can also refer the Employee to a rehabilitation consultant, which will assist the Employee in their return to work If the Employee fails to cooperate with that consultant, medical and other benefits will cease immediately.
(3) Surgical charges are payable only if pro-certification has been obtained and medical necessity recommendation has been determined by the Claims Administrator/ Managed Care Provider.
(4) Medical invoices should be paid as soon as reasonably possible, but no later than thirty (30) calendar days of receiving the invoices and medical records.
(5) The Plan will pay the cost of all reasonable and necessary charges related to the worker's injury/illness after investigation of the validity of the worker's compensation injury/illness subject to the following restrictions:
(A) The employee must have all follow-up care in the treatment of the worker's illness/injury with a licensed professional Health Care Provider. After the second visit, the Employee may not change providers without approval from the Claims Administrator/Manager Care Provider.
(B) The Plan will pay the reasonable and necessary medical costs and the cost of medicines, supplies and equipment of a therapeutic nature that are necessary for treatment of the injury or illness
(C) The Plan will pay surgical charges only when the surgery is done on an "emergency" basis, or if it has been pre-certified by the Claims Administrator/Managed Care Provider, who may request a second opinion before approving any procedures.
(D) The Plan will reimburse the Employee for cost of mileage (if documented), and other related expenses, except childcare, necessary to obtain medical treatment, if approved by the Employer, Claims Administrator/Managed Care Provider.
(E) If the Employee fails to appear for a scheduled appointment without notification to the Claims Administrator/Managed Care Provider within one business day of that appointment, then the Employer's responsibility for payment of all benefits will cease immediately. Only one rescheduled date per appointment is allowed under this Plan.
(F) The Claims Administrator/Managed Care Provider may contract for services of a rehabilitation consultant to assist the Employee in return to work efforts. If the Employee fails to cooperate in the return to work process, all benefits will cease immediately.
(b) Primary Physician
An Employee may receive initial emergency care from a Hospital ER, Urgent Care Facility or primary physician for treatment of a compensable injury. The Employee must receive follow-up care with a licensed professional Health Care Provider approved by the Claims Administrator/Managed Care Provider within seven (7) business days of initial treatment. If this policy is not adhered to it may result in denial of worker's compensation benefits.
(c) Referral to Specialty Providers
The Employee must receive the referral to specialty provider from the Medical Provider approved by the Claims Administrator/Managed Care Provider, If this policy is not adhered to it may result in denial of the worker's compensation benefits.
(d) Alternative Health Care Provider
If an Employee is dissatisfied with the medical treatment offered by the primary physician and/or approved referral physician, the Employee shall submit a written statement to the Claims Administrator/Managed Care Provider indicating the dissatisfaction and the reasons for it. Based on this statement, an agreement may be reached between the Employee and the Claims Administrator/Managed Care Provider to permit the Employee to seek an alternative Health Care Provider. The following conditions shall also apply:
(1) The Employee must receive prior approval from the Claims Administrator/Managed Care Provider before receiving any treatment/service from the alternate medical provider chosen by the Employee.
(2) If the Employee foils to obtain prior approval from the Claims Administrator/Managed Care Provider for the selected alternative Health Care Provider, the Plan shall not be responsible for any expense incurred as a result of that service/treatment.
(3) Other Health Care Providers used by the Employee may confer with and obtain information on the Employee's condition from the primary physician, approved referral physician or IME provider.
(e) Examination of Claims
Whenever an injured Employee claims compensation, the Employee must submit to an Independent Medical Examination/Evaluation (IME), or second opinion, when requested by the Claims Administrator/Managed Care Provider. The Claims Administrator/Managed Care Provider may schedule an Employee for an Independent Medical Examination or evaluation at any time during the Employee's course of medical treatment. The expense for this service, except expense for child care, will be paid by the Plan. If an Employee unreasonably fails to appear for a scheduled IME, all medical and other benefits will cease immediately.
The Claims Administrator/Manage Care Provider will provide the Employee with a written request for IME and shall notify the Employee at least five (5) workdays prior of the proposed date, time and place of examination/evaluation, and the identity of the Health Care Provider that will provide the service. Only one rescheduled date per appointment is allowed under this Plan.
The Employee is entitled to have a physician or other Health Care Provider selected by the Employee, present at any scheduled examination/evaluation, and is entitled to receive a copy of all reports prepared by the examining physician immediately upon receipt of those reports by the Claims Administrator/Managed Care Provider or the Lac Courte Oreilles Insurance Appeal Board.
The physician or Health Care Provider shall furnish to the Claims Administrator/Managed Care Provider a legible duplicate of all reports, bills and other written material requested. Any person who refuses to provide duplicates of written material in the person's custody that is required under the Ordinance shall be liable for reasonable and necessary costs including reasonable attorney fees.
(f) Temporary Total Disability
Benefits are payable when the disability results solely from a bodily injury arising in and out of the course of employment with the Lac Courte Oreilles Tribal Government. The benefits are calculated as sixty-seven (67%) of the weekly wage of the Employee at the time of the injury, and subject to a maximum of $450.00 per week. The daily wage will be calculated by using the average of the prior 26 work weeks. Disability benefits are paid only if the disability is evidenced by medical opinion based on examination and treatment rendered at the time of the claimed disability and requires an Independent Medical Examination.
(g) Temporary Partial Disability
This benefit represents sixty-seven (67%) of the difference between the pre-injury weekly wage and weekly wage the Employee earns after returning to light duty restricted modified work if the wage loss is due solely to the injury and disability suffered while in the course and scope of the employment with the Lac Courte Oreilles Tribal Government. Temporary partial disability benefits are subject to the same maximums and restrictions as temporary total disability benefits.
(h) Permanent Partial Disability
This benefit will compensate the injured Employee for any permanent loss/loss of use of a body part suffered as a result of compensable bodily injury. The designated percentage of the disability rating is multiplied by the weekly permanent disability benefit, which determines the dollar amount payable to the Employee and is allocated in one lump sum. Permanent partial disability benefits are not payable concurrently with temporary total/temporary partial benefits. To determine Permanent Partial Disability the health care provider must use the American Medical Association's "Guide to the Evaluation of Permanent Partial Impairment,'' 5th Edition.
(i) Waiting Period
For All Employees: Vacation or sick time benefits may be used for the first three (3) scheduled days lost. When verified that the Employee's claim is a legitimate work related claim and the employee is off work for ten or more calendar days, compensation is payable beginning with the first day of disability. Vacation and sick time benefits may be reconciled if used.
(j) Dependency Benefits
If an Employee dies from a work related injury or illness leaving a legal spouse and/or dependent child/children, the Employer shall make payments to the legal spouse and/or dependent child/children in an amount equal to sixty-seven percent (67%) of the Employee's average weekly wage at the time of the Employees injury or illness to a maximum of $450.00 per week. This amount will be evenly distributed to the surviving issue, if the legal spouse is deceased.
As determined by the Plan Administrator, payments to the legal spouse shall be for a maximum of one (1) year, terminating upon the remarriage or death of the spouse, whichever comes first. Payments to a dependent child/children shall be made until the dependent child/children reaches the age of 18 unless the dependent child/children is a full-time student or determined by medical evidence to be physically or mentally incapable of self-support, in which case payment shall be made to age 25.