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America’s PPO is proud to serve the needs of patients and providers by offering a Worker’s Compensation network in partnership with GENEX. The worker’s compensation product manages work related injuries or illnesses in the same way healthcare is managed, with an emphasis on return to work. The product channels employees into the America’s PPO network for care. It also applies utilization management activities to in-network and out-of-network providers.

Employee Benefits

  • Immediate, toll-free access
  • Choice of occupationally focused physicians
  • Case managers who provide understanding of treatment and recovery options
  • Internal dispute resolution
  • Goal of return-to-work

Employer Benefits

  • Immediate notification of injury or case/claim
  • Occupationally focused network
  • Highly skilled case managers who continually monitor cases and provide ongoing communication
  • Internal dispute resolution with a goal of increased employee satisfaction
  • Structured return-to-work programs

Payor Benefits

  • Timely reporting
  • Early case intervention when needed
  • Internally developed guidelines to assure that the right resources are deployed at the right time
  • Proactive communication between the GENEX team of clinical experts and payor’s staff

For More Information

Information about the GENEX/America’s PPO Workers’ Compensation Managed Care Plan is available 24 hours a day at 1-800-525-8546. You may also contact the Minnesota Department of Labor and Industry at (651)296-2432 or 1-800-342-5354 in St Paul; or (218)723-4670 or at 1-800-365-4594 in Duluth, MN.

Legislation: Workers Compensation Statutes 176.135(f), 176.1351, and 176.83

As amended by house bill 642, effective July 1, 1995
Managed Care Rule 5218 Effective: December 1, 1993

Required Components

  • The names of all directors and officers, specified personnel, and entities that the plan has joint ventures with assurance that the plan provides quality services that meet all uniform treatment standards
  • Descriptions of the times, places, and manner for providing plan services, including evidence of an adequate number of health care providers in each category to give employers and employees convenient geographic accessibility and flexible choices
  • All required health care services and providers, as specified, unless there is evidence that a service is not available in a community
  • Copies of all types of standard contracts and agreements with providers, including the corresponding directory and licensing information for each provider
  • Descriptions of programs, as specified, for peer review, utilization review, internal dispute resolution, return-to-work, workplace safety and health, and aggressive medical case management
  • A plan to inform employees about provider choices and access to those providers, dispute resolution and a copy of the managed care notice provided to employees
  • Plans must include a program to educate participating providers on required treatment parameters, MMI, PPD management, and special obligations under the workers compensation system
  • The managed care organization medical director must attend a minimum of 12 hours of continuing education during the first year and 4 hours each year thereafter
  • Plans must identify any medical treatment standards developed for services not covered by department standards and must make them available for review by the Commissioner upon request

Worker’s Compensation Updates

Per the Department of Labor and Industry, we have listed some important legislative updates from their May 2015 Compact Newsletter.

  • Section 1 amends Minnesota Statutes, section 176.135, related to electronic billing by adding a new subdivision 7a. Subdivision 7a Electronic transactions
    – Health care providers must be provided with the appropriate information needed from the payers to submit electronic claims. This information includes:
    – the payer identification number
    – the name of the clearinghouse the payer uses to transmit electronic claims
    – information about how to report the payer’s claim number on a bill
    – contact information for the payer and the payer’s clearinghouse
    – Medical Records to support a worker’s compensation bill must be sent and accepted electronically by July 1, 2016, using the most recently approved version of ASC X12N 275 attachment transaction standard.
    – Payers must provide adequate information to allow providers to match payment to specific patient bills by September 1, 2015.
    – The commissioner may assess a penalty of $500 for each violation, up to $25,000 per calendar year. The provider must be given a 30 day warning with the chance to correct the violation before receiving a penalty.
  • Section 2 amends Minnesota Stat. 176.1362, subd. 1b, Limitation of liability. Subdivision 1b was amended to reflect the new Section 3. These changes go into effect for services provided to patients discharged on or after January 1, 2016.
  • Section 3 adds a new Minn. Stat. 176.1362, Inpatient hospital payment for patient discharges on or after January 1, 2016.
    – The maximum allowed for an inpatient hospitalization will be 200 percent of Medicare for the applicable DRG using the Medicare PC-Pricer program effective January 1 of the year the patient was discharged.
    – Bills must be submitted within the time frames required by Minn. Stat. 62Q.75, subd. 3.
    – If hospital charges exceed $175,000, payment will be 75% of the hospital’s usual and customary charge instead of the MS-DRG. The $175,000 amount will be adjusted annually by the percent change in total charges per inpatient case based on the hospital data reported to the MDH, starting in 2017. The updated threshold amount will be published in the State Register.
    – Medicare-certified critical access hospitals must be paid at 100% of the hospital’s usual and customary charge instead of the MS-DRG rate.
  • Section 4 amends Min. Stat. 176.221, subd. 8, to require payment of worker’s compensation monetary benefits by electronic funds transfer (EFT), effective January 1, 2016.
  • Section 5 amends Minn. Stat. 176.231, subd. 1, to coordinate worker’s compensation and OSHA reporting requirements, as federal OSHA reporting rules have recently changed. The time frames for reporting fatalities and inpatient hospitalizations is now the same for OSHA and worker’s compensation per this amendment so the employer only needs to make one phone call.

For more updates, please check out the Compact Newsletter available on the Department of Labor and Industry’s website.

Governor Dayton Made Changes to Worker’s Compensation Law.
Effective Date: October 1, 2013

Governor Dayton signed into law a number of revisions to the Minnesota workers’ compensation statute. Please see listed below an overview of these changes.

  • Mental-Mental Claims – The definition of an occupational disease was revised to include mental impairment. Mental impairment is defined as a diagnosis of post-traumatic stress disorder diagnosed by a licensed psychiatrist or psychologist. Despite this revision to the statute, the language is quite restrictive, as it prohibits recovery from mental impairment if it results from disciplinary action, work evaluation, job transfer, layoff, demotion, promotion, termination, retirement and similar actions taken in good faith by an Employer.
  • Attorney’s Fees increased to $26,000 The 25/20 formula was removed and now a 20% fee will be applied to the benefits, creating a maximum attorney fee of $26,000. Fees for employers and insurers were also increased to $26,000 per case.
  • Subd. 7 Fees only for attorney fees based on a contingency, not medical or rehabilitation disputes The new statutory revisions eliminate partial reimbursement of attorney’s fees to employees pursuant to Minn. Stat. ?? 176.081, Subd. 7 for fees awarded on medical or rehabilitation disputes.
  • Job search limited to 26 weeks The judge cannot order more than 26 weeks of job development services.
  • 176.645 Adjustments shall not be less than 0 percent or greater than 3 percent – For injuries occurring on or after October 1, 2013.
  • $7,500 on DOLI jurisdiction not applicable if issue to be determined is whether a charge is excessive The $7,500 limited does not apply for jurisdiction over medical issues for DOLI if the determination is whether a charge for a service, article or supply is excessive under Minn. Stat. 176.136.
  • Changes to 176.521 regarding Settlements during WCCA Appeal – This provision is a procedural codification for suspending activities before the Workers Compensation Court of Appeals if the parties intend to settle their case instead of proceeding with the appeal.
  • Patient Advocate Pilot Program The revised statute introduces a two-year program for patients with back problems who are considering fusion surgery. The purpose of this provision is to better educate patients on the cost and possible risks of fusion surgery.
  • Treatment Parameters to be amended to add rules for long-term opioid use – The Treatment Parameters will be changed to add criteria for the long-term use of opioids or other “scheduled medications.”

(Reference and, 2014)
To learn more about Minnesota’s Worker’s Compensation Certified Managed Care Plans, please visit