New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter C - State Hospital Code › Article 4 - Managed Care › Part 732 - Workers' Compensation Preferred Provider Organizations › Subpart 732-1 - Provider Certification › Section 732-1.2 - Preferred provider organization certification

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Any plan, owned, operated or administered
						by an entity which has the capacity to establish a network of service providers
						to coordinate and provide all services provided or arranged for under the
						Workers' Compensation Law to diagnose, treat and rehabilitate a claimant
						requiring medical treatment of an occupational disease or accidental injury
						arising out of and in the course of employment, as enumerated in section
						732-1.1(h)(1) to
						(11) of this Subpart and to meet the
						operating standards established in Subpart 732-2 of this Part may apply to the
						commissioner for certification as a PPO. Such application shall be on forms
						provided by the Department of Health and shall be accompanied by a $500
						application fee.
(b) Each
						application for certification as a PPO shall include the following information:
(1) the standards by which the providers
						participating in the preferred provider organization will be
						selected;
(2) the names and
						credentials of all individuals and organizations, and certifications of all
						hospitals, that will provide service under the preferred provider organization,
						together with appropriate evidence of workers' compensation board
						authorizations for such individuals as well as evidence of compliance with all
						licensing or certification requirements for such individuals or organizations
						to practice in this State;
(3) a
						description of any final disposition of professional misconduct charges against
						any of the individuals or organizations which will provide medical or other
						health care services under the preferred provider organization
						program;
(4) a description of the
						times, places and manner of providing service under the preferred provider
						organization;
(5) a detailed
						description of procedures to be followed in meeting the requirements of Subpart
						732-2 of this Part for ongoing quality assurance, service utilization review
						and dispute resolution; including:
(i)
						procedures for implementing the internal dispute resolution protocol described
						in section
						732-2.2(h)(1) of
						this Part;
(ii) for disputes not
						resolved through the internal dispute resolution process, a process for
						determining whether and how to access the Workers' Compensation Board dispute
						resolution process described in section
						732-2.2(h)(2) of
						this Part;
(6) if
						incorporated, a copy of the applicant's certificate of incorporation, bylaws
						and, if applicable, certificate of doing business under an assumed
						name;
(7) if not incorporated, a
						copy of the applicant's proposed certificate of incorporation, bylaws,
						partnership agreement, application for authority to do business in New York,
						and certificate of doing business under an assumed name, as
						applicable;
(8) a description of
						the projected service area;
(9) a
						description of how access to services will be provided to claimants who reside
						outside the proposed service area;
(10) a description of how the PPO will ensure
						that at least five medical or health care providers will be made available in
						each county to claimants in each area of specialization required or offered,
						or:
(i) documentation indicating that there
						are not at least five physicians in a particular specialty in each county
						within the service area; and
(ii)
						documentation indicating that there are at least five of the following
						specialty physicians under contract within each county within the proposed
						service area: family practice (board certified GP); orthopedic surgery,
						neurology, internal medicine; physical therapist; chiropractor and surgeon;
						and
(iii) documentation indicating
						that there are at least five of the following speciality physicians under
						contract within a county or counties contiguous to one or more of the other
						counties which comprise the service area: anesthesiology, physical medicine and
						rehabilitation; psychiatry; psychology; radiology and dermatology;
						and
(iv) documentation indicating
						that there are at least five of the following speciality physicians under
						contract within the Workers' Compensation Board district office service area:
						cardiology; pulmonary disease; ophthalmology; hand surgery; pathology; plastic
						surgery; urology; podiatrist; occupational therapist, neurological surgery;
						otolaryngology; thoracic surgeon; allergy and immunology; or
(v) documentation indicating that the
						standards contained in subparagraphs (i)- (iv) of this paragraph cannot be met
						along with documentation, acceptable to the chair, in consultation with the
						commissioner, indicating how the PPO will provide claimants with an equivalent
						and accessible choice of practitioners;
(11) a description of how the PPO will ensure
						that a claimant will be able to choose from at least three hospitals within a
						radius appropriate to the care needs of claimants in the event that
						hospitalization is necessary; provided that:
(i) for urban counties, there shall be at
						least one hospital available within the county and at least two other hospitals
						available in counties other than such urban county, which are within the
						Workers' Compensation Board district office service area; and
(ii) for rural counties, where there is no
						hospital affiliated with the PPO within a travel distance from either the work
						site or claimant's home of forty miles or less, the PPO shall permit the
						claimant to be treated at the hospital nearest to either the claimant's
						worksite or home that has the capability to treat the claimant's condition, and
						shall reimburse such hospital at the established diagnosis related group
						reimbursement rate, or as otherwise authorized by law;
(12) an independently audited financial
						statement of the current financial condition of the applicant; and
(13) such other information relating to the
						certification and operation of the PPO as the commissioner may deem
						necessary.