§ 122.610. Standards for contracts and agreements with providers.
(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.
(b) A CCO that delivers services in whole or part through employed providers shall impose upon the employes the same requirements it is required to impose on contracted providers in subsection (a).
(c) An applicant for a CCO certification, which has existing provider contracts, may meet the requirements of subsection (a) through an appropriate provider contract rider, which shall be submitted as part of its application.
(d) Information relating to a CCO’s reimbursement rates, which is received by the Department under this section, shall be confidential, except that the Department may use the data, without identification of a particular provider, as part of the Department’s efforts to provide statistical reports on the operation of CCOs under the act.
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); and 34 Pa. Code § 122.609 (relating to requirements for a CCO’s health service delivery system).
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