ARKANSAS WORKERS' COMPENSATION COMMISSION Form AR-H Authority: Ark. Code Ann. � 11-9-514, AWCC Rule 7, 33 Revised 1-1-2001 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 H HEALTH CARE NOTICE FOR EMPLOYEES UNDER MANAGED CARE Your employer has contracted with the following Managed Care Organization (MCO): Name Address or has been certified as an Internal Managed Care System (IMCS). You are required to receive treatment through this MCO/IMCS if you receive a work-related injury. If you do not receive treatment through this MCO/IMCS, or you do not obtain permission to change treatment provider(s), then you may be required to pay for the treatment you receive. Emergency treatment is exempt from this requirement. Employees are covered under the MCO/IMCS after the employer posts Form H. Prior notice given to employees by a certified MCO shall fulfill the above notice requirements. The telephone number of your employer's MCO/IMCS is . You may call this number if you have questions about managed care or if you need names of physicians. If you are injured on the job, you should notify your supervisor immediately. Your supervisor will arrange for treatment or explain what you need to do to receive treatment for your injury. If you have a problem with or a dispute about this MCO/IMCS, you may file a complaint within thirty (30) days of the occurrence. To obtain information contact your supervisor, the MCO/IMCS, or the Medical Cost Containment Division at the AWCC (1-800-622-4472 or 501-682-3930). If you are balance billed by a physician for a covered workers' compensation injury, you should notify your employer. Balance billing occurs when physicians are paid according to the MCO/IMCS contract or the Arkansas Workers' Compensation Fee Schedule, the amount they were paid is less than the amount of their bill, and they attempt to collect the difference from employees. Choice/change of physician is controlled by law. Your employer may choose the initial treating physician. Any referral would be to parties abiding by MCO rules, terms, and conditions. Emergency medical treatment is exempted. If you want a change of physician, request it from the insurance carrier or employer. If the decision is unsatisfactory, you may petition the Commission for a change. "[T]he injured employee shall have direct access to any optometric or ophthalmologic medical service provider who agrees to provide services under the rules, terms, and conditions regarding services performed by the managed care entity initially chosen by the employer for the treatment and management of eye injuries or conditions. Such optometric or ophthalmologic medical service provider shall be considered a certified provider by the commission." Ark. Code Ann. � 11-9-508(e) Treatment or services furnished or prescribed other than according to the above, EXCEPT EMERGENCY TREATMENT, shall be at your own expense. H American LegalNet, Inc. www.FormsWorkFlow.com AWCC Form H (Health Notice for Managed Care) AWCC Rule 33 (Managed Care) requires employers under a Managed Care program to have posted in the workplace a notice of the Managed Care Organization (MCO) or Internal Managed Care System (IMCS). Form H, effective 1-1-2001, satisfies the requirements of revised Rule 33, effective 11-15-1999. Help with Form H is availab le from th e Me dical Co st Conta inment D ivision. Ge neral info rmation is availab le from the Support Services Division. (1-800-622-4472 or 501-682-3930) Ark. Code Ann �11-9-106(a): "Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers' compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers' Compensation Commission." American LegalNet, Inc. www.FormsWorkFlow.com