A. The director shall establish a system of case management for coordinating the health care services provided to workers claiming benefits under the Workers' Compensation Act [Chapter 52, Article 1 NMSA 1978] or the New Mexico Occupational Disease Disablement Law [52-3-1 NMSA 1978].
B. As used in this section, "case management" means the ongoing coordination of health care services provided to an injured or disabled worker, including but not limited to:
(1) developing a treatment plan to provide appropriate health care services to an injured or disabled worker;
(2) systematically monitoring the treatment rendered and the medical progress of the injured or disabled worker;
(3) assessing whether alternate health care services are appropriate and delivered in a cost-effective manner based on acceptable medical standards;
(4) ensuring that the injured or disabled worker is following the prescribed health care plan; and
(5) formulating a plan for return to work.
C. The director shall contract with an independent organization to assist with the administration of the provisions of this section.
D. Nothing in this section shall prevent an employer from establishing his own program of case management; however, for the purposes of resolving choice of health care provider disputes, an employer or worker shall only use the program as provided by the workers' compensation administration, as set forth in Section 52-1-49 NMSA 1978.
History: 1978 Comp., § 52-4-3, enacted by Laws 1990 (2nd S.S.), ch. 2, § 51.
ANNOTATIONSRepeals and reenactments. — Laws 1990 (2nd S.S.), ch. 2, § 51 repealed former 52-4-3 NMSA 1978, as enacted by Laws 1990, ch. 65, § 2, and enacted a new section, effective April 1, 1991.
Effective dates. — Laws 1990, ch. 65, § 5 made §§ 1 and 2 of the act effective July 1, 1990.
Appropriations. — Laws 1990, ch. 65, § 3, effective May 16, 1990, appropriated $750,000 from the workers' compensation administration fund to the workers' compensation division of the labor department for expenditure in the seventy-ninth fiscal year for the purpose of providing for the review and other services provided pursuant to 52-4-2 and 52-4-3 NMSA 1978.
Laws 1990 (2nd S.S.), ch. 3, § 8C, effective January 1, 1991, provided that the appropriation in Laws 1990, ch. 65, § 3 be expended for the purpose of carrying out the provisions for utilization review and case management pursuant to 52-4-2 and 52-4-3 NMSA 1978.
Legislative intent requires case managers to be under contract. — The plain language of this section demonstrates that the legislature intended that a workers' compensation administration case manager be a contractor with a contract in effect. The administrative rules implement this intent by creating a framework requiring case managers to be contractors who are paid as provided in the contract. Trace v. Univ. of N.M. Hosp., 2015-NMCA-083.
Where case manager's contract with the worker's compensation administration to coordinate health care services provided to worker expired, the workers' compensation judge was without statutory authority to order that the case manager continue providing services as worker's case manager in the absence of a contract under the Procurement Code. Trace v. Univ. of N.M. Hosp., 2015-NMCA-083.
Private case management company. — A private case management company hired by an insurer could not engage in ex parte contacts with the claimant's private physician, the claimant or the claimant's counsel. Gomez v. Nielson's Corp., 1995-NMCA-043, 119 N.M. 670, 894 P.2d 1026.
Law reviews. — For survey of 1990-91 workers' compensation law, see 22 N.M.L. Rev. 845 (1992).