CareMark Comp MCO Directory - SAIF

1 CareMark comp MCO. Medical Provider and Facilities Directory . JULY 2018. R-954. R954 CareMark comp Directory Page 2 July 2018. CareMark comp _____. SAIF, has contracted with CareMark comp , a Am I required to see one of the CareMark state-certified managed care organization comp doctors if I am injured on the job and (MCO) to provide services to employees need medical care? injured on the job. In most cases, yes. Once your claim is enrolled . We understand that dealing with an injury can with CareMark comp (which means you have sometimes be stressful and confusing. We been given written notice of your requirement to therefore recommend that you become familiar treat within the MCO) you will be required to with the CareMark comp procedures as you treat with an MCO provider unless one of the progress in treatment and healing.

2 Circumstances explained below applies. Following are answers to some of the more The situations in which you may receive commonly-asked questions concerning the compensable care from a non- CareMark comp managed care program. Should you have provider after your claim is enrolled follow. additional questions, please feel free to contact SAIF at , or CareMark comp 1. You have a private physician, directly at chiropractic physician, or nurse practitioner who qualifies as a primary What is CareMark comp ? care physician, chiropractic physician or authorized nurse practitioner. CareMark comp is a state-certified managed care organization that contracts with physicians, Your family physician, chiropractic physician, hospitals, and other health care providers to or authorized nurse practitioner may qualify provide medical services to covered employees to treat you under the managed care with work-related injuries or illnesses.

3 These arrangement, even if s/he is not on the providers are carefully selected and trained in the CareMark comp list of contracted providers. treatment of work-related conditions. CareMark To qualify: comp , and the network health care providers Your provider must be a medical doctor want to make sure that timely, effective, and (MD) or doctor of osteopathy (DO), convenient medical services are available for chiropractic physician (DC) or authorized covered workers. CareMark comp will also be nurse practitioner (ANP). working closely with your doctor and SAIF to help you return to gainful employment as soon as Your doctor must be a family practitioner, possible after an on-the-job injury or illness. general practitioner, internal medicine specialist, chiropractor, or authorized Is CareMark comp a Workers' Compensation nurse practitioner.

4 Insurance company? You must have a history of being treated by No. CareMark comp contracts with SAIF, a that doctor or authorized nurse practitioner workers' compensation insurance company. and your medical records have been CareMark comp monitors medical care that is maintained by the provider, or you have the provided to ensure it is appropriate and doctor or authorized nurse practitioner as a necessary, and it meets specific quality designated primary care provider under standards. your private group health plan. CareMark comp does not make decisions on The doctor or authorized nurse practitioner acceptance or denial of claims, payment of time must agree to abide by all terms and loss or medical benefits, or any other workers' conditions of CareMark comp , and must compensation benefits.

5 Decisions concerning refer you to a CareMark comp provider for these and all other claims issues remain the any additional care you may need. responsibility of SAIF. R954 CareMark comp Directory Page 3 July 2018. If your authorized nurse practitioner is What if I live a long distance from CareMark qualified to provide your care, s/he will be comp 's service area? allowed to provide medical treatment and If you live more than one hundred miles from authorize time loss for 180 days from the CareMark comp 's geographic service area, you date of the first nurse practitioner visit on will not be subject to the MCO arrangement. the initial claim. 2. There are fewer than three MCO. providers available in a given category What if I am currently receiving care from a in CareMark comp 's geographical non-MCO provider for a work-related injury service area.

6 Or illness at the time I am enrolled into the MCO program? You may be allowed to seek treatment from a non- CareMark comp provider if there are You will be required to begin treating with an fewer than three CareMark comp providers MCO provider, with the exceptions noted above. in the following categories: However, if you are not yet medically stationary and think that a change of physicians would be Acupuncturist (LAC) medically detrimental to you, you may request Optometrist (OD) review of your situation by the MCO. To request review, please submit your request in writing to Chiropractor (DC). the address listed within 30 days of the date of Dentist (DMD or DDS) the action. Failure to request review in writing Naturopath (ND) within 30 days precludes further appeal.

7 Osteopath ((DO). Physician (MD) What if I need help finding or scheduling an appointment with an MCO provider? Podiatrist (DPM). Physical therapist (PT) If you would like help in scheduling an appointment, or if you have contacted several Psychologist panel providers and were not able to schedule a Authorized nurse practitioner (ANP) timely appointment, please contact CareMark comp for assistance at All out-of-panel treatment will be subject to CareMark comp 's utilization and treatment standards. What do I do if there is a medical emergency and I'm not able to see a 3. You reside outside CareMark comp 's CareMark comp provider? geographical service area. In true emergency cases, CareMark comp , your If you reside outside CareMark comp 's employer, and SAIF believe the first priority is to geographical service area, you may select a take care of the medical emergency at an non-MCO provider if they practice closer to appropriate medical facility.)

8 An emergency is your residence than an MCO provider of the defined as a medical condition that if treatment is same category and if they agree to the not rendered immediately, creates the risk of terms and conditions of the MCO. death, serious disability or serious medical If you think you qualify for any of the above consequences. exceptions and would like consideration for If your claim is subject to the MCO, and you are out-of-panel treatment, please contact your far away from or otherwise unable to receive care adjuster to begin the review process. from a CareMark comp provider in an Should you receive care from a provider emergency, you should seek care from the who does not meet the above criteria for nearest appropriate medical facility.

9 After you are out-of-panel treatment, SAIF will not be out of immediate danger, all follow-up care will required to pay for medical services. be provided within the MCO. If emergency care is needed and an appropriate CareMark comp facility is available, care should be sought from the CareMark comp member facility if possible. R954 CareMark comp Directory Page 4 July 2018. If you are in need of emergency care and unsure Remember: of where to go, seek medical care from the Injured workers should remember to tell the closest available medical facility. Emergency care CareMark MCO doctor that they are injured on should not be used as a substitute for routine, the job (when, how, and the employer's name). ongoing medical care from an attending They will be asked to sign a form (Form 827) so physician.

10 They doctor can release information to SAIF. concerning the injury. Injured workers and What can I do if I disagree with an action employers should also complete the Employer's taken by CareMark comp or its member Report of Injury (Form 801). It can be submitted physicians? online (through Business Online) or downloaded and emailed faxed SAIF and CareMark comp want to make sure you ( ) or mailed (SAIF, 400 High St SE, receive timely, effective and convenient medical Salem OR 97312-1000) within five days. services for your work-related injury or illness. However, should a dispute arise concerning your care within the MCO, you may request review For more information, contact: through CareMark comp 's Internal Dispute CareMark comp Resolution Process.