Missouri Revised Statutes
Chapter 287 - Workers' Compensation Law
Section 287.135 - Managed care services, department to establish program to certify organizations, procedures — effect on fees and services.

Effective - 28 Aug 1993
287.135. Managed care services, department to establish program to certify organizations, procedures — effect on fees and services. — 1. The department of commerce and insurance shall establish a program whereby managed care organizations in this state shall be certified by the department for the provision of managed care services to employers who voluntarily choose to use such organizations. The department shall report to the division of workers' compensation all managed care organizations certified pursuant to the provisions of this section. The division shall maintain a registry of certified managed care organizations that can be readily accessed by employers for the provision of managed care services. For the purposes of this section, the term "managed care organizations" shall mean organizations such as preferred provider organizations, health maintenance organizations and other direct employer/provider arrangements which have been certified by the department designed to provide incentives to medical care providers to manage the cost and use of care associated with claims covered by workers' compensation insurance.
2. The director of the department of commerce and insurance shall promulgate rules which set out the approval criteria for certification of a managed care organization. Approval criteria shall take into consideration the adequacy of services that the organization will be able to offer the employer, the geographic area to be served, staff size and makeup of the organization in relation to both services offered and geographic location, access to health care providers, the adequacy of internal management and oversight, the adequacy of procedures for peer review, utilization review, and internal dispute resolution, including a method to resolve complaints by injured employees, medical providers, and insurers over the cost, necessity and appropriateness of medical services, the availability of case management services, and any other criteria as determined by the director. Thirty days prior to the annual anniversary of any current certification granted by the director, any managed care organization seeking continued certification shall file an application for recertification with the director, on a form approved by the director, accompanied by a filing fee established by the director by rule and any other materials specified by the director.
3. The director of the department of commerce and insurance shall promulgate rules which set out the criteria under which the fees charged by a managed care organization shall be reimbursed by an employer's workers' compensation insurer and which establish criteria providing for the coordination and integration between the managed care organization and the insurer of their respective internal operational systems relating to such matters as claim reporting and handling, medical case management procedures and billing. Such criteria shall require any such reimbursable fees to be reasonable in relation both to the managed care services provided and to the savings which result from those services. Such criteria shall discourage the use of fee arrangements which result in unjustified costs being billed for either medical services or managed care services. Insurers and managed care organizations shall be permitted to voluntarily negotiate and utilize alternative fee arrangements. Notwithstanding any provision of this subsection to the contrary, if an insurer and a managed care organization enter into a voluntary agreement that accomplishes the same purposes as this subsection, that insurer and that managed care organization with respect to that agreement shall not be required to meet the requirements of this subsection or regulations promulgated by the department pursuant to this subsection.
4. Any managed care organization, including any managed care organization that has been established or selected by or has contracted with a workers' compensation insurance carrier to provide managed care services to insured employers, that has previously been certified prior to August 28, 1993, by the director of the department of commerce and insurance shall be deemed to have met the criteria set forth in this section.
5. The necessity and appropriateness of medical care services recommended or provided by providers shall be subject to review by the division of workers' compensation, upon application, following a decision by the managed care organization's utilization review and dispute resolution review and appeal procedure. The decision of the managed care organization relating to payment for such medical care services shall be subject to modification by the division of workers' compensation, after mediation conference or hearing, only upon showing that it was unreasonable, arbitrary or capricious.
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(L. 1993 S.B. 251)

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Structure Missouri Revised Statutes

Missouri Revised Statutes

Title XVIII - Labor and Industrial Relations

Chapter 287 - Workers' Compensation Law

Section 287.010 - Citation of law.

Section 287.020 - Definitions — intent to abrogate earlier case law.

Section 287.021 - Sheriffs and deputy sheriffs to be covered by workers' compensation — average earnings defined.

Section 287.030 - Employer defined.

Section 287.035 - Partners, sole proprietors may elect to receive benefits for themselves — employees, effect — insurer's liability — intent of law — withdrawal of employee from coverage, procedure.

Section 287.037 - Member of limited liability company to receive coverage, rejection of coverage, rescission of rejection — S corporation, certain shareholders may elect or reject coverage.

Section 287.040 - Liability of employer — contractors, subcontractors.

Section 287.041 - For-hire motor carrier not an employer of a lessor — definition.

Section 287.043 - Abrogation of case law regarding definition of owner.

Section 287.060 - Employers and employees affected by this act.

Section 287.061 - Occupational or business license for construction contractors, city or county — duty to require proof of workers' compensation coverage, when, effect.

Section 287.063 - Occupational diseases, presumption of exposure — last employer liable — statute of limitations, starts running, when.

Section 287.067 - Occupational disease defined — repetitive motion, loss of hearing, radiation injury, communicable disease, others.

Section 287.070 - Occupational diseases directly related to cleanup of an illegal drug manufacturing lab.

Section 287.090 - Exempt employers and occupations — election to accept — withdrawal — notification required of insurance companies.

Section 287.100 - Legislative intent relative to other laws expressed.

Section 287.110 - Scope of chapter as to injuries and diseases covered.

Section 287.120 - Liability of employer set out — compensation increased or reduced, when — use of alcohol or controlled substances or voluntary recreational activities, injury from — effect on compensation — mental injuries, requirements, firefighte...

Section 287.123 - Insurers to establish safety engineering and management services program — requirements — division to maintain registry.

Section 287.124 - Department of labor and industrial relations, certification of employer safety programs, when.

Section 287.126 - Toll-free telephone number for workers' compensation information, division to establish.

Section 287.127 - Notice, employer to post, contents — division to develop, distribute, and publish notice, when — penalty.

Section 287.128 - Unlawful acts, penalties — fraud or noncompliance, complaint may be filed, effect — fraud and noncompliance unit established, purpose, confidentiality of records — annual report, contents.

Section 287.129 - False billing practices of health care provider, defined, effect — department of commerce and insurance, powers — penalty.

Section 287.130 - Employer's liability joint and several — contribution allowable.

Section 287.135 - Managed care services, department to establish program to certify organizations, procedures — effect on fees and services.

Section 287.140 - Employer to provide medical and other services, transportation, artificial devices, reactivation of claim — duties of health care providers — refusal of treatment, effect — medical evidence — division, commission responsibilities —...

Section 287.141 - Physical rehabilitation, defined, division of workers' compensation to administer — procedure.

Section 287.143 - Vocational rehabilitation services, not mandatory — testing and assessment.

Section 287.144 - Definitions.

Section 287.145 - Rehabilitation practitioners, providers, certification of, how.

Section 287.146 - Employee authorized to receive vocational rehabilitation, when — duties of director.

Section 287.148 - Loss of suitable, gainful employment, how determined — severe injury, defined — plan, duration, costs allowed.

Section 287.149 - Benefits to be paid, when — reduction of benefits, when.

Section 287.150 - Subrogation to rights of employee or dependents against third person, effect of recovery — construction design professional, immunity from liability, when, exception — waiver of subrogation rights on certain contracts void, employer...

Section 287.160 - Waiting period — compensation, how paid — interest, how computed — not credit to employer for wages or benefits paid, exception.

Section 287.170 - Temporary total disability, amount to be paid — method of payment — disqualification, when — post injury misconduct defined — benefits not payable, when.

Section 287.180 - Temporary partial disability, amount to be paid — method of payment.

Section 287.190 - Permanent partial disability, amount to be paid — permanent partial disability defined — permanent total and partial total disability require certification by physician on compensability — award reduced when.

Section 287.195 - Claims for hernia, proof required.

Section 287.197 - Occupational deafness — tests, claims, awards, liability of employer, effect of hearing aid.

Section 287.200 - Permanent total disability, amount to be paid — suspension of payments, when — toxic exposure, treatment of claims.

Section 287.203 - Termination of compensation by employer, employee right to hearing — assessment of costs.

Section 287.210 - Physical examination of employee — exchange of medical records — admissibility of physician's, coroner's records — autopsy may be ordered.

Section 287.215 - Injured employee to be furnished copy of his statement, otherwise inadmissible as evidence — statement, what is not to be included.

Section 287.220 - Compensation and payment of compensation for disability — second injury fund created, services covered, actuarial studies required — failure of employer to insure, penalty — records open to public, when — concurrent employers, effec...

Section 287.223 - Missouri mesothelioma risk management fund created — definitions — issuance of payments, when — board of trustees, appointment, meetings, duties.

Section 287.230 - Payment of compensation at death of employee — exceptions — abrogation of case law.

Section 287.240 - Death benefits and burial expenses, amount, to whom paid and when paid — dependent defined — death benefits, how distributed — record of dependents, employer to keep — dependents to report to division, procedure.

Section 287.241 - Death benefits, inconsistent with section 287.240, when.

Section 287.243 - Line of duty compensation — definitions — claim procedure — distribution — no subrogation rights for employers or insurers — grievance procedures — sunset date — fund created, use of moneys — rulemaking authority.

Section 287.245 - Volunteer firefighters, grants for workers' compensation insurance premiums — or cancer benefits pool.

Section 287.250 - Compensation, computation of — average weekly wage, division or commission may determine, when — additional compensation for persons under twenty-one, when — multiple employers, computation of coverage — weekly wage — compromise set...

Section 287.252 - Cafeteria plan payroll deductions, not to reduce computation of employee compensation.

Section 287.253 - Monetary bonus, effect on benefits.

Section 287.260 - Compensation to have priority — not assignable — exceptions.

Section 287.266 - Payments made to public assistance recipients to be a debt due state, recovery by state — attorney's fees — assignment of rights — apportionment by judge, when.

Section 287.270 - Benefits from other sources no bar to compensation, exception, professional athletes.

Section 287.280 - Employer's entire liability to be covered, self-insurer or approved carrier — exception — group of employers may qualify as self-insurers, requirements — rules — confidential records.

Section 287.282 - Employee leasing arrangements, coverage required.

Section 287.290 - Employee not to pay cost of insurance.

Section 287.300 - Employer's liability primary or secondary — notice and service, when sufficient.

Section 287.310 - Policies to be approved by department — deductible plans authorized, requirements.

Section 287.335 - Determinations review board, created, purpose — code classifications, classification system, review of, duties.

Section 287.340 - Insurance companies must keep reserve.

Section 287.350 - Insurance companies to make report.

Section 287.360 - Director may suspend or revoke permits and ask for a receiver.

Section 287.370 - Compensation in lieu of insurance, how provided.

Section 287.380 - Employer or insurer to make report to division, requirements — information not to be disclosed — failure to report, penalty.

Section 287.390 - Compromise settlements, how made — validity, effect, settlement with minor dependents — employee entitled to one hundred percent of offer, when — maximum medical improvement, rating from second physician, when.

Section 287.400 - Accident — duty of division — employer.

Section 287.410 - Powers and functions of the division of workers' compensation.

Section 287.420 - Written notice of injury to be given to employer — exceptions.

Section 287.430 - Limitation as to action, exception.

Section 287.440 - Limitation begins to run, when.

Section 287.450 - Failure to agree on compensation — division to hold hearings.

Section 287.460 - Division hearings, findings sent to parties and insurer — mediation services, division to establish procedures, requirements.

Section 287.470 - Commission may review and change award.

Section 287.480 - Application for review, time limit — when deemed filed — bond required, when.

Section 287.490 - Final award conclusive unless an appeal is taken — grounds for setting aside — disputes governed by this section, claims arising before August 13, 1980.

Section 287.495 - Final award conclusive unless an appeal is taken — grounds for setting aside — disputes governed by this section, claims arising on or after August 13, 1980.

Section 287.500 - Circuit court may act upon memorandum — procedure.

Section 287.510 - Temporary or partial awards may be made.

Section 287.520 - Notice — manner of serving.

Section 287.530 - Commission or division may commute compensation, when and how.

Section 287.540 - Compensation commuted — funds, how paid out.

Section 287.550 - Proceedings before commission to be informal and summary.

Section 287.560 - Division or commission may administer oaths, issue process, take depositions — depositions may be taken by electronic means — costs, how paid.

Section 287.570 - Contempt — penalty.

Section 287.580 - Death, pending proceedings — action shall not abate.

Section 287.590 - Division may be sued — official seal.

Section 287.600 - Oath of office.

Section 287.610 - Additional administrative law judges, appointment and qualification, limit on number — annual evaluations — review committee, retention vote — jurisdiction, powers — continuing training required — performance audits required — rules...

Section 287.615 - Employees of division — compensation — selection.

Section 287.620 - Attorney general legal adviser.

Section 287.630 - Forms, other material furnished by commission and division.

Section 287.640 - Necessary offices to be provided, where — salaries — traveling expenses, how paid — hearings, where held.

Section 287.642 - Public information programs, division to establish.

Section 287.650 - Division to make rules and regulations — power to destroy reports, when — rules.

Section 287.655 - Dismissal of claims, when, how, effect.

Section 287.660 - Fees.

Section 287.670 - No fees for services of public officers.

Section 287.680 - Annual report to governor.

Section 287.690 - Premium tax on insurance carriers, purpose, rate, how determined — use of funds for employers mutual insurance company, purpose.

Section 287.700 - Returns delinquent — duty of director.

Section 287.710 - Tax returns — payments — use of proceeds — funds and interest not to lapse.

Section 287.713 - Director, report of expenditures.

Section 287.715 - Annual surcharge required for second injury fund, amount, how computed, collection — violation, penalty — supplemental surcharge, amount.

Section 287.716 - Surcharge on deductible plan policyholders, when, calculation of — notification of policyholders.

Section 287.717 - Surcharge collection, procedure — failure to pay, interest assessed, when.

Section 287.720 - Companies withdrawing from state liable for taxes imposed — department of revenue empowered to collect.

Section 287.730 - Employer carrying own risk must pay tax.

Section 287.740 - Compliance with provisions obligatory — penalty for violation.

Section 287.745 - Delinquent taxes, interest, rate — overpayment of taxes, credit.

Section 287.750 - Sufficiency of notice.

Section 287.760 - Insurance carriers exempt from other tax, when.

Section 287.780 - Discrimination because of exercising compensation rights prohibited — civil action for damages — motivating factor defined.

Section 287.790 - Penalty not specifically provided — misdemeanor.

Section 287.800 - Law to be strictly construed.

Section 287.801 - Review of claims, by whom.

Section 287.804 - Waiver of compensation by employee, procedure.

Section 287.808 - Burden of proof.

Section 287.810 - Change of administrative law judge, procedure, limitations.

Section 287.811 - Discovery in workers' compensation cases, sections not to effect.

Section 287.812 - Definitions.

Section 287.813 - Retirement, administrative law judges and legal advisors — participation in state employees' retirement system required, when.

Section 287.815 - Retirement, age and service qualifications.

Section 287.820 - Benefits, amount, how payable — exemption from execution, certain judgment claims to be unassignable, exception — contributions to health care plan — consultants appointment, compensation, annual increases, how computed.

Section 287.825 - Death of member before or after retirement — benefits of beneficiaries.

Section 287.830 - Retirement with less than twelve years service — benefits.

Section 287.835 - Removal from office bars benefits — intentional killing of administrative law judge or legal advisor bars survivor benefits, when.

Section 287.840 - Practice of law after retirement — restrictions.

Section 287.845 - Administration of retirement system and funds.

Section 287.846 - Retirement benefit plan exclusive, exception — transfer of funds from other system.

Section 287.850 - Life insurance benefits.

Section 287.855 - Disability benefits.

Section 287.856 - Administrative law judges and legal advisors serving in Armed Forces may elect to purchase creditable prior service — contributions, payment period — surviving spouse may receive refund.

Section 287.860 - Guaranty association, created, all self-insured to be members — powers — withdrawing member, duties.

Section 287.862 - Board of directors, members, appointment, qualifications — director to be member — terms, vacancies — expense reimbursement.

Section 287.865 - Moneys not deemed state moneys — use of funds — reports to director, when — additional powers of corporation — assessments, division shall levy, amount — no dividends to be paid — bankruptcy, dissolution, or insolvency of self-insur...

Section 287.867 - Insolvency fund, created — purposes, audit of.

Section 287.870 - Plan of operation, submitted to division, when — purpose, contents — effective, when.

Section 287.872 - Powers and duties of division.

Section 287.875 - Assignment of recovery rights to corporation, when — receiver or liquidator, rights — corporation to file statements with receiver, when.

Section 287.877 - Insolvent member, board may determine, how — notice to division, when.

Section 287.880 - Liability, limitation of.

Section 287.882 - Automatic stay of proceedings, when, duration.

Section 287.885 - Limitations on actions.

Section 287.886 - Severability clause.

Section 287.892 - Workers' compensation insurers to report cost data to department.

Section 287.894 - Insurers to report medical claims data to division of workers' compensation, contents — consolidated health plan, duties — purpose — costs — penalty for failure to comply.

Section 287.896 - Residual market, department to develop plan — insurers to participate, rates, procedures — duties of director.

Section 287.900 - Citation of law — definitions.

Section 287.902 - Missouri employers mutual insurance company, created, powers, purpose.

Section 287.905 - Board, created — members, appointment, qualifications, terms — chairman.

Section 287.907 - Administrator, hiring of, qualifications, compensation — powers of board, generally.

Section 287.909 - Administrator, duties of, bond required — immunity from liability, board and employees.

Section 287.910 - Rates, board to determine, how.

Section 287.912 - Investment policy, board to determine — administrator to make investments, how.

Section 287.915 - Agents may sell policies, commissions.

Section 287.917 - Workplace safety program, administrator to formulate — safety plan, contents — rates may be reduced, when.

Section 287.919 - Company not to receive state appropriation, exception — revenue bonds, authorization, terms, execution, procedures.

Section 287.920 - Audit required, when, procedure — report, contents, governor and general assembly to receive — administrator to formulate budget — department, duties — subscribers to be provided policy, when.

Section 287.930 - Definitions.

Section 287.932 - Act not applicable, when — unfair trade practices, when.

Section 287.935 - Insurer and advisory organization not to make agreement restraining trade — insurer must use uniform experience rating plan — exceptions.

Section 287.937 - Director may conduct examinations — insurer and advisory organizations to maintain records, purpose — cost of examination — outstate examination may be accepted.

Section 287.940 - Penalties for violations, director may impose — each day a separate violation, when — license may be suspended or revoked, when.

Section 287.942 - Competitive market presumed to exist, when — reasonable degree of competition, factors.

Section 287.945 - Director to monitor degree of competition, purpose.

Section 287.947 - Insurers to file rate information in competitive market with the director, purpose — noncompetitive market, information filed — form of filing — public inspection.

Section 287.950 - Competitive market, rates not to be excessive, inadequate, unfairly discriminatory.

Section 287.952 - Rate standards in noncompetitive market, factors.

Section 287.955 - Insurers to adhere to uniform classification system, plan — director to designate advisory organization, purpose, duties — risk premium modification plan, requirements.

Section 287.957 - Experience rating plan, contents.

Section 287.960 - Disapproval of rate, when, how — procedures, director's powers — effect.

Section 287.962 - Hearings, when, conduct of — findings made, when — right to judicial determination.

Section 287.965 - Aggrieved party may file application with director, hearing held, when — findings, effect of.

Section 287.967 - Advisory organization must obtain license, restrictions — license, application — designation of by director, duration.

Section 287.970 - Advisory organization not to file rates on behalf of insurer, exception.

Section 287.972 - Advisory organization's permitted activities — director may allow pure premium rate data to be distributed.

Section 287.975 - Pure premium rate, schedule of rates, filed with director, when — payroll differential, advisory organization to collect data, when, purpose — construction group, submission to advisory organization.