34 Pa. Code § 122.626. Contracts with independent organizations for performance of case management and communication or utilization review services.

§ 122.626. Contracts with independent organizations for performance of case management and communication or utilization review services.

(a)  A CCO shall provide quality assurance and injured worker grievance system services directly.
(b)  A CCO may, with the prior approval of the Department, contract with an independent organization for the conduct of utilization review or case management and communication services for injured workers treated by the CCO.
(c)  A CCO that intends to enter into a contract subject to subsection (b), after it becomes certified, shall submit the contract for review and approval by the Department before it enters into the contract.
(d)  The CCO will be held by the Department to have ultimate responsibility and accountability for services provided by a contractor to injured workers pursuant to a contract subject to subsection (b).
(e)  A contract subject to subsection (b) shall contain provisions which provide that:
   (1)  The ultimate responsibility and accountability for services provided by the contractor to injured workers is retained by the CCO.
   (2)  The CCO has authority to establish performance standards, monitor performance of the contractor, require corrective action and terminate the contract if the contractor is found by the CCO to be ineffective or to be conducting activities detrimental to the CCO or injured workers.
   (3)  The Department has approval authority over the contract and authority to require the CCO to take corrective action.
   (4)  The CCO and the Department shall have access to records, including medical records, relating to the provision of services to injured workers electing to receive care through the CCO.

Cross References

   This section cited in 34 Pa. Code §  122.608 (relating to contents of an application for certification as a CCO); and 34 Pa. Code §  122.612 (relating to standards for utilization review).

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