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 732-2 - Operations › Section 732-2.6 - Records, reports and information requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Clinical records shall be made available
						for review by the commissioner and otherwise afforded confidentiality in
						accordance with applicable State law, including laws on confidentiality of HIV
						records, and unwarranted access shall be prevented.
(b) The PPO shall report to the commissioner
						information regarding disciplinary action against any provider or information
						regarding professional misconduct.
(c) All other business records and data
						maintained by the PPO, and relevant to the commissioner's authority to oversee
						the activities of the PPO and to determine the appropriateness of continued
						certification, either pursuant to applicable law or in the normal conduct of
						business, shall be made available to the commissioner and/or chair upon
						request.
(d) The PPO shall develop
						a detailed plan for providing affected employees with written notice of the PPO
						arrangement for the treatment of all workers' compensation injuries and
						illnesses. Such written notice shall also advise potential claimants where they
						may obtain a handbook which contains written information about the PPO as
						described in subdivision (e) of this section.
(e) The PPO shall develop a handbook, a
						limited number of which shall be distributed by an appropriate party to all
						participating employers, upon the entering of a contract between the PPO and
						the carrier. The handbook shall be written in an understandable manner.
						Employers will be expected to reproduce the handbook in sufficient numbers to
						provide copies to employees on an as-needed basis. The handbook shall contain:
(1) all information needed by an employee to
						access services and programs offered by the PPO, including 24 hour emergency
						care;
(2) the procedures for
						selecting and changing providers within the PPO network;
(3) a full explanation of all rights and
						responsibilities of the PPO, employer and employee when services are
						required;
(4) a detailed
						description of the policies and procedures of the PPO including service
						utilization review policies and procedures;
(5) the manner in which medical
						determinations are made in the PPO/workers' compensation area;
(6) a listing of all participating providers,
						including address and telephone number, their specialties, any board
						certification and the means of initiating contact;
(7) a description of how such providers are
						reimbursed;
(8) a description of
						the process for obtaining a second opinion, which the claimant may seek from
						another provider within the PPO at any time, with respect to a proposed medical
						treatment;
(9) a description of the
						process for opting out of PPO care which shall include:
(i) the right of the claimant to seek medical
						treatment from outside the PPO 30 days after his or her first visit to a PPO
						provider; and
(ii) the right of an
						employer to require, under such circumstances, a second opinion from a provider
						within the PPO;
(10) a
						description of how the PPO addresses the needs of non-English speaking
						claimants;
(11) the procedure for
						filing grievances against the PPO, the location and/or phone number where
						grievances may be filed and the procedure for processing and resolving
						grievances;
(12) a description of
						the process by which claimants may participate in a written evaluation of the
						PPO and thereby influence changes in policies and procedures;
(13) the procedure for filing a complaint
						with the Workers' Compensation Board and/or the Department of Health;
(14) the procedure for obtaining a referral
						to the New York State Occupational Health Clinics Network when the claimant
						chooses to obtain treatment at such clinics for occupational disease;
						and
(15) general claimant education
						material which will assist the claimant in obtaining care.