§ 122.608. Contents of an application for certification as a CCO.
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.
(2) An organization chart listing reporting relationships and the positions supporting the operations of the CCO, particularly in the areas of utilization review, quality assurance, case management and communication and provider relations. An addendum to the chart shall describe how increased utilization of CCO services will affect staffing and staffing to injured worker ratios.
(3) A description of the geographic service area by county in which the CCO proposes to operate. The description shall demonstrate how the applicant will comply with § 122.609 (relating to requirements for a CCO’s health service delivery system).
(4) A complete list of participating coordinated care providers:
(i) Identifying whether the provider is an employe or affiliate of or has entered into a contract or agreement with the CCO.
(ii) Identifying the geographic area—usually county—in which each provider practices and its specialty.
(iii) Explaining how the CCO’s contractual arrangements with providers meet the requirements of § 122.610 (relating to standards for contracts and agreements with providers).
(5) A map of the proposed service area indicating the location of participating coordinated care providers.
(6) A copy of the generic contract the applicant will utilize to contract with workers’ compensation insurers and self-insured employers to offer its services and negotiate provider rates of payment.
(7) A copy of literature in draft or final form that the applicant will utilize to market its services to workers’ compensation insurers, self-insured employers and injured workers, and a copy of injured worker literature which meets the requirements of § 122.625 (relating to injured worker literature). If final-form literature is not available for submission with the application and the applicant meets the other standards, the Department will conditionally certify the applicant as a CCO if it has provided draft literature, conditioned upon its submission of literature in final form within 60 days of approval. The Department will withdraw the conditional certification if the final-form literature is not submitted to it within the 60 days or if the literature is not satisfactory to the Department.
(8) A description of the manner in which an injured worker initially selecting the CCO shall gain access to treatment by a participating coordinated care provider. This document shall meet the requirements of § 122.609.
(9) A copy of generic form contracts, or letters of agreement, and compliance riders used by the applicant to contract with participating coordinated care providers. These documents shall meet the requirements of § 122.610.
(10) A description of how the applicant’s case management and evaluation system meets the requirements of § 122.611(a) (relating to standards for a case management and evaluation system and case communication system), and a copy of the written record required by § 122.611(a)(1).
(11) A description of the applicant’s case communication system which demonstrates how the applicant meets the standards of § 122.611(c).
(12) A description of the applicant’s utilization review system which demonstrates how the applicant meets the standards of § 122.612 (relating to standards for utilization review), and a copy of the documentation specified in § 122.612(a)(6)(i).
(13) A description of the applicant’s quality assurance system which demonstrates how the applicant meets the standards of § 122.613 (relating to standards for quality assurance program), and a copy of the documentation specified in § 122.613(2), (5) and (6).
(14) A description of the applicant’s written grievance system which demonstrates how the applicant meets the standards of § 122.615 (relating to injured worker grievance system and provision of alternatives), and a copy of the documentation specified in § 122.615(g).
(15) If the applicant seeks exemption of a provision in section 306(f.2)(2) and (3) of the act (77 P. S. § 531.1(2) and (3)), the specific requirements from which it seeks exemption and the justification for the applicant’s inability to meet the requirements.
(16) A description of the injured worker satisfaction survey process the applicant will utilize to survey injured workers who have been treated by the CCO which demonstrates how the applicant meets the standards of § 122.614 (relating to injured worker satisfaction program).
(17) A copy of the proposed single service referral, provider participation and payment agreement, if any, to be utilized by the applicant to coordinate and manage referrals, which demonstrates how the applicant meets the standards of § 122.609(c)(2).
(18) A copy of the policy face sheet or other evidence that the applicant has medical malpractice liability insurance or errors and omissions liability insurance, as appropriate, for the liability risks assumed by the applicant.
(19) A copy of a contract with an independent organization from which the applicant chooses to purchase case management and communication or utilization review services, if it chooses not to provide the services directly through its own employed staff or the staff of an affiliate/subsidiary, which demonstrates how the applicant meets the requirements of § 122.626 (relating to contracts with independent organizations for performance of case management and communication or utilization review services).
Cross References This section cited in 34 Pa. Code § 122.607 (relating to recertification).
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