§ 122.611. Standards for a case management and evaluation system and case communication system.
(a) A CCO shall establish, operate and maintain a case management and evaluation system which includes continuous monitoring of treatment from onset of the injured worker’s injury or illness until the injured worker leaves the care of the CCO, and which meets the following standards. The system shall:
(1) Maintain a written record of staffing of its case management and evaluation system, the professional expertise of the staff and staffing to injured worker ratios.
(2) Be staffed by an adequate number of trained and experienced registered nurses and rehabilitation specialists who are trained and experienced in workers’ compensation or disability management and supervised by appropriate clinicians.
(3) Monitor an injured worker’s progress through appropriate daily or weekly contact with the injured worker and persons providing health services to the injured worker.
(4) Assist the injured worker, the worker’s family and participating coordinated care providers treating the worker to develop appropriate treatment plans and make referrals within the CCO network.
(5) Work with participating coordinated care providers and injured workers to develop treatment and discharge plans, work-hardening programs and physical, occupational and vocational rehabilitation therapy.
(6) Coordinate return to work plans with employers and recommend part-time or light duty work plans.
(7) Identify an injured worker’s abilities and skills and match them with work opportunities.
(8) Prohibit the implementation of a treatment plan and referral under paragraph (4), and prohibit the implementation of another implement plan under paragraphs (5) and (6), without securing the injured worker’s consent.
(b) A CCO may combine its utilization review and case management functions and departments.
(c) A CCO shall establish, operate and maintain a case communication system which periodically relates necessary and appropriate information concerning the injured worker, as required by the act, among the injured worker, the injured worker’s employer, health care providers and the employer’s workers’ compensation insurer. Dissemination of this information shall be solely for the purpose of providing treatment to or coordinating care for the injured worker.
(d) The CCO shall be prohibited and shall prohibit its providers, employes or agents who may obtain, be provided with or acquire information as a result of the CCO’s treatment of an injured worker, from releasing the information to another person without the consent of the injured worker, except as required by the act or regulations.
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).
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
