Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 122 - GENERAL PROVISIONS OF ACT 57 OF 1996-STATEMENT OF POLICY › Subchapter G - COORDINATED CARE ORGANIZATIONS-STATEMENT OF POLICY › Section 122.602 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
Act
-The Workers' Compensation Act
					 (77
					 P. S. §§
											1-1031).
Adequate access
-A reasonable distance an
					 injured worker must travel to secure primary medical services through a CCO,
					 generally not greater than a 30-minute non-rush hour drive from the worker's
					 home or place of employment, whichever is the more appropriate point.
Bureau
-The Bureau of Health Care Financing
					 of the Department.
CCO-Coordinated Care Organization
-An
					 organization licensed in this Commonwealth and certified by the Department to
					 provide medical services to an injured worker after it demonstrates that it has
					 met the criteria for certification as a CCO established by section 306(f.2) of
					 the act (77 P. S. §
											531.1).
Case management
-A collaborative process,
					 system or service which assesses, plans, supports, implements, coordinates,
					 monitors and evaluates options and services to meet an injured worker's health
					 needs through communication and available resources to promote quality
					 cost-effective outcomes, and which deals primarily with the social, personal
					 and economic factors relevant to a worker's injury, but which does not include
					 the actual provision of medical care, treatment or services.
Department
-The Department of Health of the
					 Commonwealth.
Injured worker
-A worker or employe
					 entitled to or claiming compensation or medical benefits under or covered by
					 the act.
Organization licensed in this
					 Commonwealth
-A single entity-that is, a partnership, corporation, and
					 the like-which is authorized to do business in this Commonwealth and which has
					 a clearly identifiable and unified administrative and functional structure as
					 determined by the Department.
Participating coordinated care provider
-A
					 provider who is employed by a CCO or a CCO affiliate or who has entered into an
					 agreement or contract with a CCO, and who provides treatment, accommodations,
					 products or health services to injured workers pursuant to that
					 relationship.
Primary medical services
-The following
					 services frequently utilized by injured workers:
(i) Inpatient hospital medical surgical
				  services.
(ii) Hospital emergency
				  room or urgent care center services.
(iii) Primary care physician-family
				  practitioner or general internal medicine-services.
(iv) Diagnostic imaging facility
				  services.
(v) Inpatient and
				  outpatient physical therapy and rehabilitation services.
(vi) Rehabilitation medicine specialist
				  services.
(vii) Orthopedic
				  specialist services.
(viii) General
				  surgery specialist services.
(ix)
				  Ophthalmology specialist services.
(x) Chiropractic services.
(xi) Neurological specialist
				  services.
(xii) Mental health
				  professional services.
Single service referral, provider participation and
					 payment agreement
-A combined referral form and provider agreement
					 utilized by a CCO to refer an injured worker to a provider who has not entered
					 into a general contract or agreement with the CCO to treat the injured workers
					 referred by the CCO.