New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 6 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Subchapter 2 - NEW JERSEY WORKERS' COMPENSATION MANAGED CARE ORGANIZATIONS › Section 11:6-2.4 - Requirements of approved workers' compensation managed care organizations

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The WCMCO shall file an annual report with the Department of Banking and Insurance by April 30th of each year on a form provided by the Department, which can be found on the Department's website:
http://www.nj.gov/dobi/division_insurance/managedcare/wcmco.htm
, and which shall include income, expenses, gains or losses, number of new cases received since the prior report, number of claims submitted since the prior report, total provider charges, and total sums paid to providers. The annual report shall be submitted to the following address:
New Jersey Department of Banking and Insurance
Office of Consumer Protection Services
Managed Care
Attn: Workers' Compensation MCO Annual Report
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
(b) The WCMCO shall report all changes in operations to the Department within 30 days of said change(s), including, but not limited to, contractual changes, name changes, mergers, acquisitions, sales of the WCMCO and/or the preferred provider organizations serving as the network or any changes to the nature of the WCMCO's operations as reflected in its application and supporting materials filed pursuant to 11:6-2.5 at the address shown in (a) above.
(c) For purposes of providing medical services to injured workers under a workers' compensation insurance policy as set forth in this subchapter, a WCMCO shall meet the following criteria:
1. The WCMCO shall arrange for the full range of medical and rehabilitative services necessary to treat injured workers, including, but not limited to, primary care, orthopedic care, inpatient care, emergency care, physical therapy and occupational therapy. In the aggregate, services provided outside of the WCMCO network should not exceed 20 percent of the WCMCO's cost of medical and rehabilitative services provided to injured workers.
2. The WCMCO shall provide geographic access by county to emergency, medical and rehabilitative services for employer sites covered under its program. Such services may be delivered directly, under contract, or through written referral protocol;
3. The WCMCO shall have medical care direction provided and supported by medical directors as defined in this subchapter;
4. The WCMCO shall provide medical management, catastrophic case management, disability case management and monitoring. These case management services must be supported by documented medical and disability protocol and should be generally accepted by the medical community;
5. The WCMCO shall track and manage an injured worker's progress from the onset of injury through case resolution;
6. The WCMCO shall contract with participating health care and rehabilitation providers who are credentialed by the WCMCO according to their documented criteria, which must specifically include the provider's ability to handle workplace injuries and illnesses;
7. The WCMCO shall provide written dispute resolution and grievance procedures to assure that disagreements with medical providers are resolved without jeopardizing or disrupting patient management;
8. The WCMCO shall provide reports as may be required by the Commissioner in areas including, but not limited to, medical utilization, disability data and costs of the WCMCO;
9. The WCMCO shall possess the resources, financial and otherwise, necessary to sustain required services;
10. The WCMCO shall establish and implement a fraud detection plan in accordance with the provisions of 11:6-2.1 1;
11. The WCMCO shall establish and implement an early return-to-work program in accordance with the provisions of 11:6-2.1 3; and
12. The WCMCO shall establish and implement a peer and utilization review program and a utilization management program in accordance with the provisions of 11:6-2.1 4.