reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.17 - Change in compensation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If an
				injured employee has recovered from an injury, or a deceased employee's
				dependent or personal representative is no longer eligible to receive death
				benefits, an Agreement to Stop Weekly Workers' Compensation Payments (Final
				Receipt), Form LIBC-340, may be executed by the parties. The executed agreement
				shall be filed with the Bureau.
(b)
				Termination, suspension, modification or other change in compensation may be
				accomplished by filing with the Bureau a Supplemental Agreement for
				Compensation for Disability or Permanent Injury, Form LIBC-337. A Supplemental
				Agreement for Compensation for Disability or Permanent Injury, Form LIBC-337,
				may be used to change an Agreement for Compensation for Disability or Permanent
				Injury, Form LIBC-336, a Supplemental Agreement for Compensation for Disability
				or Permanent Injury, Form LIBC-337, an Agreement for Compensation for Death,
				Form LIBC-338, a Notice of Compensation Payable, Form LIBC-495, or an award. A
				Supplemental Agreement for Compensation for Disability or Permanent Injury,
				Form LIBC-337, shall be completed before being signed by the employer and the
				employee. The completed Supplemental Agreement for Compensation for Disability
				or Permanent Injury, Form LIBC-337, shall be sent to the employee or his
				dependents and filed with the Bureau.
(c) A suspension or modification of
				compensation may be accomplished by the employer mailing a Notification of
				Suspension or Modification Pursuant to §§ 413 (c) and (d), Form
				LIBC-751, to the Bureau and the employee. The wage calculation on the
				Notification of Suspension or Modification Pursuant to §§ 413 (c) and
				(d), Form LIBC-751, shall be completed for a modification.
(d) If temporary payments made under §
									121.7a (relating to notice of
				temporary compensation payable) are stopped, the employer shall file one of the
				following:
(1) A Notice Stopping Temporary
				Compensation, Form LIBC-502, and a Notice of Workers' Compensation Denial, Form
				LIBC-496, within 5 days of the last payment and within the 90-day temporary
				compensation payable period.
(2) A
				Notice of Compensation Payable, Form LIBC-495.
(3) An Agreement for Compensation for
				Disability or Permanent Injury, Form LIBC-336.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.18 - Subrogation

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If an employee
				obtains a third-party recovery under section 319 of the act (77 P. S. §
										671), a Third Party Settlement Agreement,
				Form LIBC-380, shall be executed by the parties.
(b) If credit is requested against future
				compensation payable, a Supplemental Agreement for Compensation for Disability
				or Permanent Injury, Form LIBC-337, may also be filed with the Bureau,
				including the amount and periodic method of pro rata reimbursement of attorney
				fees and expenses.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.20 - Commutation of compensation under section 412 of the act (77 P. S. section 791)

Current through Register Vol. 54, No. 28, July 13, 2024
Commutation under section 412 of the act (77 P. S. §
										791) shall only be allowed for the final
				  52-week period or less. The commutation amount may not be paid in installments.
				  A Commutation of Compensation, Form LIBC-498, shall be filed with the
				  Bureau.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.21 - Reimbursements for silicosis, anthraco-silicosis or coal workers' pneumoconiosis

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Claims for compensation for silicosis, anthraco-silicosis or coal workers'
				pneumoconiosis as defined in section 108(q) of the act (77 P. S. §
										27.1(q)), for disability or
				death, when the date of disability commences or death occurs between July 1,
				1973, and June 30, 1976, inclusive, and when the liable employer is seeking to
				offset part of its liability under section
				305.1 of the act (77 P. S. §
										411.1), shall be instituted by filing a Claim
				Petition for Workers' Compensation, Form LIBC-362, with the Bureau.
(b) Unless stayed by a supersedeas on appeal,
				following the issuance of an award by the workers' compensation judge, the
				Board or the appellate court, compensation payments for silicosis,
				anthracosilicosis or coal workers' pneumoconiosis shall be made in full by the
				insurer. If the insurer seeks reimbursement from the Bureau under section 305.1
				of the act, it shall submit the following to the Bureau:
(1) A notarized statement, signed by an
				officer of the company, containing an itemized list of payments made to all
				claimants for quarterly reimbursement. Each itemized entry must contain the
				claimant's name, address, Social Security number and the total amount paid to
				the claimant. Each itemized list shall be made for a full and exact calendar
				quarter: that is, January 1 through March 31; April 1 through June 30; July 1
				through September 30; or October 1 through December 31. Each list must have two
				categories: recurring quarterly reimbursement and initial payment made to each
				claimant, which payment should include the current reimbursable quarter. Each
				list submitted must be in roster form and in numerical order according to the
				claimant's Social Security number, contain the claimant's name and Social
				Security number, cover the amount to be reimbursed and the total amount paid to
				the claimant, and be reported to the Bureau.
(2) Each bill containing the itemized entries
				shall be submitted to the Bureau no later than the 15th day of the month
				following the end of the calendar quarter for which reimbursement is sought. A
				bill received after that date will not be considered for payment until the end
				of the following quarter.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.22 - Subsequent injury fund

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				Compensation for a subsequent injury, as defined in section
				306.1 of the act (77 P. S. §
										516) shall be paid as follows:
(1) The employer is responsible for payments
				due for specific loss under section 306(c) of the act (77 P. S. §
											513).
(2) Upon expiration of the specific loss
				period, the Bureau will be responsible for additional compensation due for the
				duration of total disability. The fund established under section 306.2 of the
				act (77 P. S. §
											517), from
				which these payments are to be made, shall be maintained as follows:
(i) Self-insured employers shall pay
				assessments in amounts determined by the following:
Amount of Compensation Paid by a Self-insured
							 Employer During the Preceding Calendar Year
______________
x
The Amount Expended
							 from the Subsequent Injury Fund during the Preceding Calendar Year
Total Amount of Compensation Paid by All Insurers
							 During the Preceding Calendar Year
(ii)
				The amount expended from the Subsequent Injury Fund during the preceding
				calendar year, minus the total amount owed by all self-insured employers, as
				calculated under subparagraph (i), shall equal the aggregate amount to be
				collected by insurance carriers.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.23 - Supersedeas fund

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Annual
				assessments under section 443 of the act (77 P. S. §
										999) shall be in amounts determined by the
				following:
(1) Self-insured employers shall
				pay assessments in amounts determined by the following:
Amount of Compensation Paid by a Self-insured
							 Employer During the Preceding Calendar Year
_____________
x
The Amount of
							 Supersedeas Payments Made or Accrued as Payable during the Preceding Calendar
							 Year
Total Amount of Compensation Paid by All Insurers
							 During the Preceding Calendar Year
(2)
				The amount of supersedeas payments made or accrued as payable during the
				preceding year, minus the total amount owed by all self-insured employers, as
				calculated under paragraph (1), shall equal the aggregate amount to be
				collected by insurance carriers.
(3) Insurance carriers shall remit to the
				Bureau assessment amounts as follows:
Amount of Earned Premium as Reported to the Insurance
							 Department, by an Insurance Carrier for the Preceding Calendar
							 Year
_____________
x
Aggregate Amount to
							 be Collected by Insurance Carriers
Total Amount of Earned Premium Reported to the
							 Insurance Department by all Insurance Carriers for the Preceding Calendar Year
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.25 - Issuance of compensation payments

Current through Register Vol. 54, No. 28, July 13, 2024
Compensation payments shall be issued according to the
				  following:
(1) Unless the claimant and
				the employer have executed an Authorization for Alternative Delivery of
				Compensation Payments, Form LIBC-10, or unless payment is otherwise ordered by
				a workers' compensation judge, the Board or any court, a claimant's payment for
				workers' compensation or occupational disease compensation shall be mailed by
				first-class mail to the claimant's last known address, and may not be made
				payable to, or delivered to, an attorney unless the attorney is the
				administrator or executor of the claimant's estate, a court-appointed trustee,
				a court-appointed guardian or acting in some other fiduciary
				capacity.
(2) Notice of the first
				payment to a claimant shall be sent to counsel of record by the insurer or
				self-insured employer.
(3) If a
				workers' compensation judge or the Board approves attorneys' fees and costs, a
				payment for fees and costs, separate from a compensation payment, shall be made
				payable, and issued, to the claimant's attorney.
(4) An employer may not require a claimant to
				appear at a specific place to receive compensation payments.
This section cited in 34 Pa. Code §
											121.31 (relating to timely
					 delivery of workmen's compensation
					 checks).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.27 - Orders to show cause

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				Department may serve an order to show cause on a respondent for an alleged
				violation of the act or regulations contained in this part. The order to show
				cause will contain the particulars of the alleged violation and the procedures
				for filing an answer under subsection (b).
(b) A written answer to the order to show
				cause may be filed no later than 20 days after the date that the order to show
				cause is served on the respondent. The answer must admit or deny the
				allegations in the order to show cause and state respondent's defense. General
				denials that are unsupported by specific facts will not comply with this
				section and may be deemed a basis for entry of a final order because the
				respondent has raised no issues requiring further proceedings. The facts in the
				order to show cause may be deemed admitted if a respondent fails to file a
				timely answer under this subsection.
(c) The Director of Adjudication will assign
				the order to show cause to a presiding officer who will schedule a hearing. The
				presiding officer will provide notice to the parties of the hearing date, time
				and place.
(d) The hearing will be
				conducted under this section and 1 Pa. Code Part II (relating to General Rules
				of Administrative Practice and Procedure) to the extent not specifically
				superseded in subsection (h). The presiding officer will not be bound by strict
				rules of evidence.
(e) Hearings
				will be stenographically recorded and the transcript of the proceedings will be
				part of the record.
(f) If the
				respondent fails to appear in person or by counsel at the scheduled hearing
				without adequate excuse, the presiding officer will decide the matter on the
				basis of the order to show cause and evidence presented.
(g) The Department has the burden to
				demonstrate, upon a preponderance of the evidence, that the respondent failed
				to comply with the act or regulations in this part.
(h) This section supersedes 1 Pa. Code
				§§
									35.14,
				35.37, 35.131, 35.201 and
				35.221.
This section cited in 34 Pa. Code §
											125.19 (relating to additional
					 powers of Bureau and orders to show
					 cause).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.27a - Bureau intervention and penalties

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the workers' compensation judge
				determines that penalties resulting from an alleged violation of the act or
				regulations in this part may be imposed on a party under section 435 of the act
				(77
				P. S. §
										991), the workers' compensation
				judge may notify the Bureau in writing within 20 days of the notice of the
				alleged violation.
(b) The workers'
				compensation judge will include a description of the nature of the alleged
				violation in the notice and will provide the Bureau with an opportunity to
				participate in the proceeding as an intervening party. The workers'
				compensation judge simultaneously will provide a copy of the notification to
				all parties.
(c) Within 20 days
				after receipt of the notice, the Bureau will notify the workers' compensation
				judge and the parties of its decision to participate in the proceeding or to
				allow the proceeding to continue without intervention. If the Bureau fails to
				respond to the notification within 20 days, the Bureau will not have
				intervened. By not intervening before the workers' compensation judge, the
				Bureau has not waived its right to intervene in a different forum or following
				additional notice from the workers' compensation judge in the same
				proceeding.
(d) Nothing in this
				section may be construed to require the Bureau to intervene in any matter or to
				restrain a workers' compensation judge from notifying the Bureau of a further
				alleged violation of the act or regulations in a case.
(e) This section supplements §§
									131.121 and
				131.122 (relating to penalty
				proceedings initiated by a party; and other penalty proceedings).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.30 - Section 306(h) payments (77 P. S. 583)

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Under section 306(h) of the act
				(77
				P. S. §
										583), insurers shall submit a
				listing of all pre-August 31, 1993 cases on which compensation is still payable
				under sections 306(a), 306(23) or 307 of the act (77 P. S. §§
										511,
				513(23), 561, 562 and 542),
				in an amount less than $100 per week on January 1, 2007. This listing must
				contain the following particulars:
(1) Bureau
				code.
(2) Name of
				claimant.
(3) Social Security
				number.
(4) Claimant's date of
				birth.
(5) Date of
				injury.
(6) Name of
				employer.
(7) Insurer claim
				number.
(8) Current weekly
				compensation rate.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.31 - Workmen's Compensation Administration Fund

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Annual assessments on self-insured
				employers, under section 446(b) of the act (77 P. S. §
										1000.2(b)), shall be in
				amounts determined by the following:
Amount of Compensation Paid by a Self-insured
							 Employer during the Preceding Calendar Year
____________
x
The Approved Budget of
							 the Workmen's Compensation Administration Fund for the Current Fiscal Year
Total Amount of Compensation Paid by All Insurers
							 During the Preceding Calendar Year
(b)
				The approved budget of the Workmen's Compensation Administration Fund for the
				current fiscal year, minus the total amount owed by all self-insured employers,
				as calculated under subsection (a), shall equal the aggregate amount to be
				collected by insurance carriers.
(c) Insurance carriers shall remit to the
				Bureau assessment amounts as follows:
Amount of Earned Premium as Reported to the Insurance
							 Department, by an Insurance Carrier for the Preceding Calendar
							 Year
______________
x
Aggregate Amount to
							 be Collected by Insurance Carriers
Total Amount of Earned Premium Reported to the
							 Insurance Department by all Insurance Carriers for the Preceding Calendar
							 Year
(d)
				If the amount of earned premium as reported to the Insurance Department, by an
				insurance carrier, for the preceding calendar year is less than zero, the
				Bureau will calculate the assessment amount as though an earned premium amount
				of zero were reported to the Insurance Department.
(e) Insured employers shall remit assessment
				amounts through their insurance carriers, according to procedures defined by
				the approved rating organization and approved by the Insurance
				Commissioner.
(f) Self-insured
				employers and runoff self-insurers shall pay assessments directly to the
				Bureau.
The provisions of this §
											121.31 issued under section 2218
					 of The Administrative Code of 1929 (71 P. S. §
												578).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.32 - Office of Small Business Advocate

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				The Bureau may collect annual assessments imposed on insurance carriers, but
				not on self-insured employers or runoff self-insurers, for the purpose of
				funding the Office of Small Business Advocate in accordance with section 1303
				of the act (77 P. S. §
										1041.3).
				Insurance carriers shall be directly liable to the Bureau for prompt payment of
				assessments for the Office of Small Business Advocate, as provided in the act
				and this chapter.
(b) Annual
				assessments under section 1303 of the act shall be in amounts as determined by
				the following formula:
Amount of Compensation Paid by an Insurance Carrier,
							 but not a Self-insured Employer or Runoff Self-insurer, During the Preceding
							 Calendar Year
______________
x
The Approved Budget
							 of the Office of Small Business Advocate for the Current Fiscal Year
Total Amount of Compensation Paid by All Insurance
							 Carriers, but not Self-insured Employers or Runoff Self-insurers, During the
							 Preceding Year
The provisions of this §
											121.32 issued under section 2218
					 of The Administrative Code of 1929 (71 P. S. §
												578).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.33 - Collection of special funds assessments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Bureau will collect assessments for
				the special funds by calculating the total amount of the following:
(1) What each self-insured employer is liable
				for paying to the Bureau.
(2) What
				each insurance carrier is responsible for collecting from insured employers and
				remitting to the Bureau.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.34 - Objections to assessments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A party
				receiving a notice of assessment amount to be collected from the Bureau may,
				within 15 days of receipt, object to the assessment reflected in the notice on
				the basis that it is excessive, erroneous, unlawful or invalid. Insured
				employers retain all rights provided under section 717 of the act
				(77
				P. S. §
										1035.17).
(b) Objections must be set forth in numbered
				paragraphs, specifically state the facts necessary to determine the validity of
				the challenged assessment or assessment amount and be accompanied by a
				supporting memorandum documenting the legal grounds for the
				objections.
(c) An objection to
				assessment or assessment amount shall be accompanied by a proof of service as
				specified in 1 Pa. Code §
									33.35 (relating to proof of
				service) and a notice of appearance as specified in 1 Pa. Code §
									31.24 (relating to notice of
				appearance), and be served on all interested parties as specified in 1 Pa. Code
				§
									33.32 (relating to service by a
				participant).
(d) An objection not
				conforming to this section or the act will be rejected by the Bureau. The
				Bureau will notify the objecting party of the specific reasons for the
				rejection. The objecting party shall have 30 days to cure any
				deficiency.
(e) Upon receipt of an
				objection which conforms to this section and the act, the Department will hold
				a hearing in accordance with 1 Pa. Code Part II (relating to General Rules of
				Administrative Practice and Procedure). After the hearing, the Department will
				record its findings on any objections and will transmit to the objector, by
				registered or certified mail, notice of the amount, if any, charged against it
				in accordance with the findings. The amount shall be paid by the objector
				within 10 days after receipt of the findings. After payment has been made, the
				objector may initiate an action in the appropriate court to recover the payment
				of the assessment or any portion thereof. An insurer may not maintain an action
				to recover payment unless it has previously objected under subsection
				(a).
The provisions of this §
											121.34 issued under section 2218
					 of The Administrative Code of 1929 (71 P. S. §
												578).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 121 - GENERAL PROVISIONS › Section 121.35 - Annual reports of compensation paid

Current through Register Vol. 54, No. 28, July 13, 2024
Every annual report of compensation paid made by an insurer
				  under sections 445 and 446(e) of the act (77 P. S. §§
										1000.1 and
				  1000.2(e)) must include
				  amounts paid by an insurer for which policyholders have agreed to reimburse the
				  insurer under deductible policies issued under section 448 of the act
				  (77
				  P. S. §
										1000.4).
The provisions of this §
											121.35 issued under section 2218
					 of The Administrative Code of 1929 (71 P. S. §
												578); amended under sections
					 401.1 and 435(a) of the Workers'
					 Compensation Act (77 P. S. §§
												710 and
					 991(a); and section 2205 of
					 The Administrative Code of 1929 (71 P. S. §
												565).
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 122.601 - Applicability and purpose

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This
				  subchapter provides information to employers, workers' compensation insurers,
				  providers, provider organizations and injured workers concerning how the
				  Department proposes to exercise its authority under the act to certify and
				  monitor CCOs. The information will enable potential applicants for
				  certification to commence the application process. This subchapter is not, and
				  does not purport to be, a regulation. It does not, therefore, have the force of
				  law. Rather, it expresses the present intentions of the Department with respect
				  to implementing the certification program.
(b) This subchapter should be reviewed by
				  persons who undertake to establish, operate and maintain a CCO.
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 122.603 - Uncertified CCOs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An individual,
				  partnership, corporation or other entity may not operate or maintain a CCO
				  unless it has been certified as a CCO by the Department.
(b) In determining whether an entity requires
				  certification as a CCO, the Department will consider whether it engages in any
				  of the activities described in or required by §§ 122.609-122.613 and
				  122.615.
(c) The Department will
				  not consider an entity which engages in activity limited to case management to
				  require certification as a CCO if the entity does not hold itself out as or
				  operate as a CCO.
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 122.604 - Application process

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An applicant
				  for certification as a CCO shall submit the following to the Bureau:
(1) Two copies of a completed application
				  form, available from the Bureau, Room 1026 Health and Welfare Building, Post
				  Office Box 90, Harrisburg, Pennsylvania 17108-0900.
(2) Two copies of written documentation to
				  supplement its application and establish that it meets the requirements in the
				  act and this subchapter.
(3) A
				  certified check in payment of the application fee as established by
				  regulation.
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 122.605 - Certification application fees

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will establish a certification application fee by regulation. The
				  regulation will establish the procedures and requirements for paying this
				  fee.
(b) The Department anticipates
				  that the application fee will be approximately $1,500. The Department also
				  anticipates that it will bill persons for the fee if they applied prior to the
				  effective date of the regulation, and that issuance of an initial certificate
				  or a renewal certificate may be conditioned upon payment of the fee.
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 122.606 - Certification periods

Current through Register Vol. 54, No. 28, July 13, 2024
A certificate will be valid for 2 years from the date of
					 its issue, unless the certificate is earlier suspended or revoked by the
					 Department for failure of the CCO to meet the provisions of section 306(f.2)(4)
					 of the act (77 P. S. §
											531.1(4)) or applicable
					 regulations.
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 122.607 - Recertification

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A CCO shall
				  apply for recertification as a CCO no later than 120 days prior to the
				  expiration date of its certification.
(b) The Department will establish a fee to
				  apply for recertification by regulation. The Department anticipates that the
				  fee will be approximately $1,500.
(c) An application for recertification shall
				  include information the Department may require to demonstrate that the CCO has
				  been operating and will continue to operate in accordance with the act and this
				  subchapter.
(d) A CCO applying for
				  recertification shall also include the following in its recertification
				  application:
(1) A detailed report of the
				  status of the completion of its quality assurance work plan, as set forth in
				  the initial application for certification or subsequent application for
				  recertification.
(2) A summary of
				  the results of the injured worker satisfaction surveys.
(3) A summary of changes, and documentation
				  relevant to those changes as required by §
											122.608 (relating to contents of
				  an application for certification as a CCO), if the information or documentation
				  which was required for CCO certification under §
											122.608 has changed since the most
				  recent application and has not been previously reported to or approved by the
				  Department.
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 122.608 - Contents of an application for certification as a CCO

Current through Register Vol. 54, No. 28, July 13, 2024
An application for certification as a CCO shall include the
					 following:
(1) Ownership information,
				  including the following:
(i) A disclosure of
				  whether the applicant is owned or controlled, directly or indirectly, by a
				  self-insured employer or a workers' compensation insurer.
(ii) A list of the owners of the proposed CCO
				  with a 5% or greater ownership interested.
(iii) A chart of the relationship between the
				  proposed CCO, its parent and other subsidiaries of the parent corporation, if
				  the proposed CCO is a subsidiary or affiliate of another corporation.
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 122.609 - Requirements for a CCO's health service delivery system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An applicant, to be certified or
				  recertified, and a CCO to maintain a CCO certification, shall have the
				  following:
(1) An adequate number and
				  specialty distribution of licensed participating coordinated care providers to
				  provide primary and other medical services to injured workers.
(2) The capacity to provide all primary
				  medical services to injured workers.
(3) The establishment and maintenance of
				  referral capacity to treat other injuries and illnesses.
(4) A system which provides timely delivery
				  of health care services to the injured worker.
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 122.611 - Standards for a case management and evaluation system and case communication system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A CCO shall
				  establish, operate and maintain a case management and evaluation system which
				  includes continuous monitoring of treatment from onset of the injured worker's
				  injury or illness until the injured worker leaves the care of the CCO, and
				  which meets the following standards. The system shall:
(1) Maintain a written record of staffing of
				  its case management and evaluation system, the professional expertise of the
				  staff and staffing to injured worker ratios.
(2) Be staffed by an adequate number of
				  trained and experienced registered nurses and rehabilitation specialists who
				  are trained and experienced in workers' compensation or disability management
				  and supervised by appropriate clinicians.
(3) Monitor an injured worker's progress
				  through appropriate daily or weekly contact with the injured worker and persons
				  providing health services to the injured worker.
(4) Assist the injured worker, the worker's
				  family and participating coordinated care providers treating the worker to
				  develop appropriate treatment plans and make referrals within the CCO
				  network.
(5) Work with
				  participating coordinated care providers and injured workers to develop
				  treatment and discharge plans, work-hardening programs and physical,
				  occupational and vocational rehabilitation therapy.
(6) Coordinate return to work plans with
				  employers and recommend part-time or light duty work plans.
(7) Identify an injured worker's abilities
				  and skills and match them with work opportunities.
(8) Prohibit the implementation of a
				  treatment plan and referral under paragraph (4), and prohibit the
				  implementation of another implement plan under paragraphs (5) and (6), without
				  securing the injured worker's consent.
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 122.614 - Injured worker satisfaction program

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  A CCO shall continually conduct injured worker satisfaction surveys designed to
				  ascertain at least the following regarding injured workers:
(1) Satisfaction with the participating
				  coordinated care providers, as well as nonparticipating referral providers who
				  have treated them.
(2) Satisfaction
				  with the coordination of care, case management and referrals.
(3) Promptness of appointments and
				  treatment.
(4) Overall satisfaction
				  with the quality of care provided.
(5) Satisfaction with the return to work plan
				  and outcome.
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 122.615 - Injured worker grievance system and provision of alternatives

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The CCO shall
				  maintain and offer the injured worker the following alternatives if the injured
				  worker is dissatisfied with the quality of care or quality of service of a
				  participating coordinated care provider:
(1)
				  The right to choose another participating coordinated care provider to provide
				  the required medically necessary services at no cost to the injured
				  worker.
(2) The opportunity to
				  transfer to one of the other providers specified in the list provided by the
				  employer under section 306(f.1)(1)(i) of the act (77 P. S. §
												531.1(1)(i)), during the
				  first 30 days of treatment or to transfer to an eligible provider
				  thereafter.
(3) The right to file a
				  complaint under the provisions of the CCO's injured worker grievance
				  system.
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 122.616 - External quality assessment of CCOs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) To ensure that CCOs are providing the
				  high-quality care required by the act and that provision of care through CCOs
				  is not resulting in inadequate treatment, poor quality care or inappropriate
				  release of injured workers to return to work, the Department may arrange for
				  external quality reviews of CCOs.
(b) The Department may direct that an
				  external quality review of a CCO be conducted at any time.
(c) The Department may arrange for external
				  quality reviews of a sample of CCOs to independently determine the quality of
				  care being provided by CCOs. If a sample analysis reveals significant quality
				  of care problems or lack of CCO commitment to documented and effective
				  oversight of quality of care being provided to injured workers, the Department
				  may then require all CCOs to undergo an external quality assessment.
(d) An external quality assessment shall be
				  conducted by an external quality review organization acceptable to the
				  Department and selected by the CCO from a list of Department-approved review
				  entities.
(e) An external quality
				  assessment is designed to study the quality of care being provided to injured
				  workers and the effectiveness of the CCO's formal quality assurance structure
				  and activities. It shall include a review of randomly selected medical records
				  of injured workers treated by the CCO to judge matters such as compliance with
				  medical record standards, appropriateness of diagnosis and treatment,
				  appropriateness of referrals, continuity of care and underutilization of
				  services.
(f) The CCO shall be
				  responsible for contracting with the external quality review organization and
				  paying for its services.
(g) The
				  external quality review organization and the CCO shall arrange an acceptable
				  date, time, place and agenda for the external review with the Department and
				  provide Department staff with full rights of participation in and observation
				  of the external review.
(h) The CCO
				  shall arrange for the external quality review organization to issue a formal
				  written report of its findings to the board of directors of the CCO and to the
				  Department. The Department will utilize this report as an independent fact
				  finding report and consider it in the Department's decision as to whether to
				  require a corrective action plan of the CCO, and what the components of that
				  plan should be, or whether the Department should pursue action to suspend or
				  revoke the CCO certification.
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 122.617 - Corrective action plans

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the
				  Department determines through direct examination or through an external quality
				  review that there are deficiencies in a CCO's operations, the Department will
				  identify the deficiencies to the CCO in writing.
(b) The CCO shall submit a corrective action
				  plan within 30 days of its receipt of a deficiency letter from the
				  Department.
(c) The Department may
				  initiate action to revoke or suspend the certification of a CCO that fails to
				  meet the Department's requirements for an acceptable corrective action plan
				  within 90 days of the date of the initial deficiency letter or for failure of a
				  CCO to implement a corrective action plan which the Department has
				  approved.
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 122.618 - Exemptions for rural CCOs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
				  applicant for certification as a CCO seeking to operate in a county designated
				  as rural by the Health Care Financing Administration or in a rural Health
				  Professional Shortage area may request an exemption from compliance with one or
				  more requirements of section 306(f.2)(2) and (3) of the act (77 P. S. §
											531.1(2) and (3)). A request
				  shall justify the exemption sought.
(b) In reviewing the request for exemption,
				  the Department will consider whether the potential public benefit outweighs the
				  potential public harm attributable to the requested exemption.
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 122.619 - Access to records; inspections of CCOs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The CCO shall permit the Department and
				  its employes and agents complete and free access to the books, records, papers
				  and documents of the CCO to enable the Department to perform its
				  responsibilities under the act to ensure that the services provided by a CCO
				  are in accordance with the plan for providing services included in its approved
				  application, and that the services which are provided meet accepted
				  professional standards for high quality, cost-effective care.
(b) The Department may review the actions or
				  operations of a CCO to ensure its continuing compliance with standards, to
				  address quality of care complaints or grievances or to validate data submitted
				  in CCO reports. A review may include onsite inspection of the CCO's facilities
				  and records.
(c) The CCO shall
				  permit the Department and its employes and agents access to the medical records
				  of injured workers treated by or through a CCO for the purposes of assessing
				  quality of care and for the purposes of reviewing injured worker grievances and
				  complaints.
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 122.620 - Role of the CCO in billing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
				  CCO, to ensure reimbursement of its participating coordinated care providers in
				  accordance with the reimbursement arrangements it may negotiate with an
				  employer or workers' compensation insurer, may do the following:
(1) Require the bills of participating
				  coordinated care providers for treatment of injured workers selecting the CCO
				  to be sent to the CCO for repricing in accordance with its contract with the
				  employer or workers' compensation insurer.
(2) Forward repriced, accurate bills to the
				  self-insured employer or the employer's workers' compensation insurer for
				  direct payment to the participating coordinated care provider.
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 122.621 - Referrals within a CCO

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Neither
				  a CCO nor any of its participating coordinated care providers is prohibited
				  from referring an injured worker for a medical good or service specified in
				  section 306(f.1)(3)(iii) of the act (77 P. S. §
											531.1(3)(iii)) to another
				  participating coordinated care provider within the CCO network, irrespective of
				  whether the CCO or the referring participating coordinated care provider has a
				  financial interest in the participating coordinated care provider to whom the
				  referral is made.
(b) The CCO and
				  its participating coordinated care providers shall provide to the injured
				  worker a written disclosure of their financial interests, if any, in a provider
				  to which referrals may be made.
(c)
				  The CCO shall monitor the referrals to ensure quality, guard against
				  overutilization, ensure that no referrals prohibited under section
				  306(f.1)(3)(iii) of the act are made to nonparticipating coordinated care
				  providers, and ensure that no referrals are made to persons other than the
				  participating coordinated care providers within the network unless preapproved
				  by the CCO.
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 122.622 - Prohibition of risk-transfer to CCOs

Current through Register Vol. 54, No. 28, July 13, 2024
A CCO may not accept financial risk for the provision of
					 services to injured workers without securing appropriate licensure under the
					 laws of the Commonwealth as a risk-assuming insurer, establishing appropriate
					 systems to guard against the potential for undertreatment or poor quality care
					 arising out of the incentive to minimize financial risk, and securing specific
					 prior review and approval by the Department to assume the financial risk for
					 the provision of services as a CCO.