Illinois Administrative Code › Title 50 - INSURANCE › Part 2051 - PREFERRED PROVIDER PROGRAMS › Section 2051.315 - Workers' Compensation Network Availability and Adequacy Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
a) WC PPP
			 administrators and insurers must file a description of the services to be
			 offered through a WC PPP. The description shall include:
1) The method of marketing the
			 program;
2) A geographic map of the
			 area proposed to be served by the program by county and zip code, including
			 marked locations for preferred providers;
3) The names, addresses and specialties of
			 the providers who have entered into preferred provider agreements under the
			 program;
4) The number of
			 beneficiaries estimated to be covered by the providers listed in subsection
			 (a)(3);
5) An Internet website and
			 toll-free telephone number for insureds, beneficiaries and prospective
			 beneficiaries to access up-to-date lists of preferred providers, as well as any
			 other information necessary to conform to this Part. A WC PPP shall identify
			 specific providers in a beneficiary's area, confirm specific provider
			 participation or provide a listing of specific preferred providers in the
			 delivery mode requested by the beneficiary. Preferred provider lists requested
			 by phone must be sent within 3 working days. The up-to-date provider list
			 applies to all providers that have entered arrangements to provide services
			 directly under the program or indirectly through another administrator. WC PPP
			 administrators' and insurers' Internet website addresses shall be prominently
			 displayed on all advertisements, marketing materials and brochures;
6) A description of how health care services
			 to be rendered under the preferred provider program are reasonably accessible
			 and available to beneficiaries. Standards shall address:
A) The type of health care services to be
			 provided by the administrator;
B)
			 The ratio of providers to beneficiaries, by specialty and including primary
			 treating physicians, when applicable under the contract, necessary to meet the
			 health care needs and service demands of the estimated covered
			 employees;
C) Written policies and
			 procedures for determining when the program is closed to new providers desiring
			 to enter into preferred provider arrangements;
D) Written policies and procedures for adding
			 providers to meet patient needs based on increases in the number of
			 beneficiaries, changes in the patient to provider ratio, changes in medical and
			 health care capabilities, and increased demand for services;
E) If applicable, procedures for making
			 referrals within and outside the network;
F) Efforts to address the needs of
			 beneficiaries with limited English proficiency and literacy and/or diverse
			 cultural and ethnic backgrounds, and to comply with the Americans With
			 Disabilities Act of 1990;
7) If a WC PPP administrator is leasing,
			 buying or otherwise using another administrator's or insurer's program and the
			 required information has previously been filed by the other administrator or
			 insurer, only the administrative agreement and verification that the providers
			 have consented to the agreement pursuant to Section
			 2051.300(d)
			 need to be filed. A clause within the provider contract allowing assignment
			 will be deemed consent in the absence of material modification of the
			 provider's obligations under the contract; and
8) A statement that covered employees are not
			 responsible for any costs associated with medical record transmission or
			 duplication in order to have a claim adjudicated.