§ 122.615. Injured worker grievance system and provision of alternatives.
(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.
(b) The CCO shall offer the following alternatives to an injured worker who contests denial of medically necessary treatment or services by the CCO or a participating coordinated care provider as a result of a CCO utilization review or case management decision, or otherwise:
(1) The right to have the CCO arrange for a second clinical opinion by a participating coordinated care provider, at no cost to the injured worker, concerning the medical necessity or appropriateness of treatment to which the injured worker alleges being denied access.
(2) The right to have the injured worker’s claim reviewed, at the CCO’s expense, by a non-CCO affiliated utilization review organization approved by the Department of Labor and Industry.
(3) The right to transfer to one of the other providers specified on the list provided under section 306(f.1)(1)(i) of the act, during the first 30 days of treatment or to transfer to any eligible provider thereafter.
(4) The right to file a complaint under the CCO’s injured worker grievance system.
(c) The CCO shall establish, operate and maintain an injured worker grievance system as one of the remedies available to the injured worker.
(d) The injured worker grievance system shall include:
(1) A verbal or written complaint filed by an injured worker with the CCO, as the first level of grievance. The CCO shall make a good faith attempt to address the complaint and offer an appropriate remedy or corrective action within 7 working days of its receipt of the complaint.
(2) A formal written grievance filed by the injured worker with the CCO if the injured worker is dissatisfied with the CCO’s response to the first level grievance resolution or response, as the second level of grievance.
(i) The CCO shall appoint a grievance committee to conduct an informal hearing on the injured worker’s grievance. The CCO may not permit a person who has had prior involvement in the review of the grievance committee. The CCO shall provide the injured worker or the injured worker’s representative the opportunity to be heard. The CCO is encouraged, but not required, to include worker representation on the grievance committee.
(ii) The CCO shall require that the grievance committee’s informal hearing be held in a timely fashion and its written decision be rendered promptly after the hearing. Generally, the conducting of the informal hearing within 20 days of the injured worker’s filing of a grievance, and the rendering of the decision of the grievance committee within 10 days of the informal hearing shall be considered prompt.
(iii) The CCO shall ensure that the decision on the formal written grievance includes the committee’s rationale for its decision and written notification to the injured worker of the right to appeal the decision to the Department.
(iv) The CCO shall require that a transcript be taken of the informal hearing and that the record of the informal hearing be forwarded to the Department if the injured worker appeals the decision of the grievance committee.
(3) The CCO shall ensure that for issues involving medically urgent treatment in which time may be of the essence, the injured worker may ask for expedited review and is aware of that option. The CCO shall provide expedited review of the grievance by its medical director. The medical director shall decide the grievance, inform the injured worker in writing of the decision and rationale for it, and inform the injured worker of the worker’s right to appeal the decision to the Department. In these cases, the medical director’s decision shall be rendered within 48 hours of the injured worker’s request for an expedited grievance review.
(d) The injured worker shall have the right to appeal a decision of the CCO’s grievance committee or medical director to the Department. The Department will have authority to overturn the decision of the grievance committee or medical director and order the CCO to afford the injured worker an appropriate remedy or to improve its quality of care to the injured worker.
(e) The CCO shall be responsible for paying the cost of independent clinical opinions from qualified providers or utilization review organizations approved by the Department of Labor and Industry which are requested by the Department to assist it in considering a grievance appeal.
(f) The CCO shall maintain a log of complaints and grievances filed by injured workers, in which the CCO shall record response times and dispositions, and shall make the log available for review and inspection by the Department.
(g) The CCO shall provide to an injured worker who communicates dissatisfaction with the quality of care or service received or who claims denial of medically necessary treatment or services, a written description of alternative remedies available to the injured worker and of the grievance system.
Cross References This section cited in 34 Pa. Code § 122.603 (relating to uncertified CCOs); and 34 Pa. Code § 122.608 (relating to contents of an application for certification as a CCO).
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