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 122.612 - Standards for utilization review

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  A CCO shall have an organized system for the review of the utilization of
				  services rendered by the CCO and its participating coordinated care providers
				  to injured workers to avoid the provision of poor quality care to injured
				  workers which may arise from either underutilization or overutilization of
				  services. A CCO may engage in prospective, concurrent or retrospective review
				  without obtaining a separate approval from the Department of Labor and Industry
				  as a utilization review organization, subject to the following conditions:
(1) The CCO shall place responsibility for
				  compliance with utilization review requirements, particularly precertification
				  requirements, upon its participating coordinated care providers and not upon
				  injured workers.
(2) The CCO shall
				  prohibit participating coordinated care providers from collecting payment from
				  injured workers for care provided by the provider but rejected for payment by
				  the CCO and the payor as being medically unnecessary, or for a financial
				  penalty or fee reduction imposed on the provider due to its failure to follow
				  CCO precertification requirements.
(3) The CCO shall conduct utilization review
				  on treatment provided to an injured worker only for the 30-day period it is
				  entrusted with treatment of the injured worker by virtue of the injured worker
				  having initially selected the CCO from the health care provider list offered by
				  the employer under section 306(f.1)(1)(i) of the act (77 P. S. §
												531.1(1)(i)), and during the
				  time that the injured worker continues to utilize the CCO for treatment of the
				  work-related injury.
(4) The CCO
				  shall have an adequate procedure for a participating coordinated care provider
				  dissatisfied with the initial utilization review decision to appeal that
				  decision. An injured worker dissatisfied with an initial utilization review
				  decision shall have the right to appeal that decision through the grievance
				  process.
(5) The CCO shall make
				  decisions regarding pretreatment certification and appeals from utilization
				  review decisions within 7 days of the request and provide notice of its
				  decision to the provider and injured worker.
(6) The CCO shall do the following:
(i) Maintain a written record of staffing
				  within its utilization review system; the professional experience of the staff;
				  staffing to injured worker ratios; and the basis and source of the criteria,
				  standards and guidelines the CCO uses in conducting utilization and return to
				  work case management review.
(ii)
				  Disclose to its participating coordinated care providers its utilization review
				  criteria, standards and guidelines.
(iii) Make available its utilization review
				  criteria, standards and guidelines to injured workers utilizing the CCO, their
				  employers and workers' compensation insurers.
(iv) Utilize qualified and experienced
				  registered nurses to make initial utilization review decisions.
(v) Base treatment or service denials on the
				  clinical review by a qualified physician or practitioner of the service under
				  review.