§ 122.609. Requirements for a CCO’s health service delivery system.
(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.
(b) To establish that it meets the standards in subsection (a)(1) and (2), an applicant for certification or recertification as a CCO shall present evidence that it employs, owns or has acceptable provider contracts or agreements with a suf ficient number and distribution of providers within a reasonably defined service area within which an injured worker shall have adequate access to primary medical services.
(c) To establish that it meets the standards in subsection (a)(3), an applicant for certification or recertification as a CCO shall demonstrate that it has written procedures to do at least one of the following:
(1) Enter into an agreement with the provider to whom the injured worker is to be referred by which the provider agrees to treat the injured workers referred by the CCO. The agreement shall meet the requirements of § 122.610 (relating to standards for contracts and agreements with providers).
(2) Enter into an agreement with the provider to whom the injured worker is to be referred, when a referral becomes necessary, by which the provider agrees to treat the specific injured worker being referred. The agreement which may be referred to as a single service, provider referral, participation and payment agreement, shall be subject to approval by the Department, but because of its limited nature, need meet only the following requirements instead of the requirements of § 122.610. The agreement shall:
(i) Contain identification of the CCO initiating the referral, the injured worker being referred, the referral services requested and the payor source—workers’ compensation insurer or self-insured employer.
(ii) Include a provision asserting that by signing the form and submitting a bill to the payor, the provider accepting the referral agrees to limited participation in the CCO for the named injured worker only.
(iii) Include a provision by which the provider to whom the injured worker is to be referred agrees to cooperate with the CCO’s case management, utilization review and quality assurance systems as applied to the care provided the named individual injured worker, and agrees to abide by the decisions of these CCO systems.
(iv) Include a provision by which the provider to whom the injured worker is to be referred agrees to accept the fee level negotiated by the CCO as payment in full for services it provides the injured worker which are covered under the act.
(v) Include a provision by which the provider to whom the injured worker is to be referred agrees to provide the CCO and the Department access to the injured worker’s medical records.
(vi) Include a provision asserting that the provider to whom the injured worker is to be referred accepts that the injured worker’s signature on the referral form constitutes permission to release the injured worker’s medical records regarding treatment by that provider to the CCO and the Department.
(d) To establish that it meets the standards for timely delivery of health care services in subsection (a)(4), an applicant for a CCO certification or recertification shall present evidence in the form of written policies and procedures, pro vider contract or agreement requirements or otherwise, which demonstrates that the CCO health service delivery system will meet and continue to meet the following conditions:
(i) Medically necessary urgent care shall be provided within 24 hours of the request for the care by the injured worker or another person, on the injured worker’s behalf, if the injured worker is incapable of making the request.
(ii) If referral for specialty care is required, the referral shall occur within 48 hours of the identification of the need for the specialty care and the specialty care shall be provided or arranged for within 96 hours of identification of the need for specialty care.
(iii) Nonurgent care shall be provided or arranged for within 7 days of the request for the care.
Cross References This section cited in 34 Pa. Code § 122.603 (relating to uncertified CCOs); 34 Pa. Code § 122.608 (relating to contents of an application for certification as a CCO); 34 Pa. Code § 122.610 (relating to standards for contracts and agreements with providers); 34 Pa. Code § 122.623 (relating to data reporting requirements); and 34 Pa. Code § 122.624 (relating to requirements for service area expansion).
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