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 122.610 - Standards for contracts and agreements with providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A contract or agreement between a CCO and
				  a participating coordinated care provider, unless the provider is employed by
				  the CCO or is an affiliate/subsidiary of the CCO, shall contain the following
				  minimum provisions necessary to enable the CCO to coordinate and manage care in
				  a high quality manner and protect injured workers:
(1) A provision requiring the participating
				  coordinated care provider to accept the CCO reimbursement schedule as payment
				  in full for services covered by the act which are rendered to an injured
				  worker.
(2) A provision prohibiting
				  the participating coordinated care provider from collecting or attempting to
				  collect from an injured worker payment for treatment or service provided by the
				  provider and determined by the CCO not to be medically necessary or in
				  accordance with clinical protocols established by the CCO. The provision shall
				  likewise prohibit the participating coordinated care provider from collecting
				  or attempting to collect from an injured worker a financial penalty imposed
				  upon the provider for failure to abide by the CCO's precertification or other
				  utilization review or case management requirements.
(3) A provision requiring the participating
				  coordinated care provider to abide by the CCO's standards for medical records
				  and to provide medical record access to the CCO and the Department or an
				  external quality review organization approved by the Department and selected by
				  the CCO or the Department to review the quality of care being provided by the
				  CCO.
(4) A provision requiring the
				  participating coordinated care provider to participate in and abide by the
				  decisions of the CCO's quality assurance, utilization review and injured worker
				  grievance systems.
(5) A provision
				  requiring the participating coordinated care provider to abide by the internal
				  rules, regulations and guidelines of the CCO regarding referrals, case
				  management, case communication, data reporting requirements and other matters
				  affecting the internal administration of the CCO's delivery system.
(6) A provision requiring the participating
				  coordinated care provider to promptly report to the CCO a change in its status
				  under the CCO's credentialing requirements, including loss or diminishment of
				  hospital privileges and loss or restriction of license.
(7) A provision requiring the participating
				  coordinated care provider to provide or arrange for the provision of medically
				  necessary services as required by §
											122.609 (relating to requirements
				  for a CCO's health service delivery system).
(8) A provision requiring the participating
				  coordinated care provider to accept referrals from the CCO or other
				  participating coordinated care providers within the CCO network, and whenever
				  possible and medically appropriate, to refer injured workers to participating
				  coordinated care providers within the CCO network within the time frames and in
				  accordance with other standards in § 122.609.
(9) A provision setting forth the
				  circumstances under which a participating coordinated care provider may
				  discontinue treatment of or refuse treatment to an injured worker with whom the
				  provider has failed to establish a provider-patient relationship and requiring
				  the referral of the injured worker to another appropriate provider within the
				  time frames in § 122.609(d).
(10) A provision requiring that no change in
				  the provider contract or agreement shall be effective, except for changes
				  required by the Department, without 30 days advance notice and the opportunity
				  to cease participation in the CCO if the changes are unacceptable to the
				  participating coordinated care provider.
(11) A provision requiring the participating
				  coordinated care provider to abide by the CCO's and the Department's
				  confidentiality requirements.
(12)
				  A provision specifying the contract or agreement termination rights and
				  termination notice requirements for both the CCO and the participating
				  coordinated care provider. Both the CCO and the participating coordinated care
				  provider shall have the right to terminate the contract or agreement with no
				  more than 60 days advance notice.