§ 122.602. Definitions.
The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:
Act—The Workers’ Compensation Act (77 P. S. § § 1—1031).
Adequate access—A reasonable distance an injured worker must travel to secure primary medical services through a CCO, generally not greater than a 30-minute non-rush hour drive from the worker’s home or place of employment, whichever is the more appropriate point.
Bureau—The Bureau of Health Care Financing of the Department.
CCO—Coordinated Care Organization—An organization licensed in this Commonwealth and certified by the Department to provide medical services to an injured worker after it demonstrates that it has met the criteria for certification as a CCO established by section 306(f.2) of the act (77 P. S. § 531.1).
Case management—A collaborative process, system or service which assesses, plans, supports, implements, coordinates, monitors and evaluates options and services to meet an injured worker’s health needs through communication and available resources to promote quality cost-effective outcomes, and which deals primarily with the social, personal and economic factors relevant to a worker’s injury, but which does not include the actual provision of medical care, treatment or services.
Department—The Department of Health of the Commonwealth.
Injured worker—A worker or employe entitled to or claiming compensation or medical benefits under or covered by the act.
Organization licensed in this Commonwealth—A single entity—that is, a partnership, corporation, and the like—which is authorized to do business in this Commonwealth and which has a clearly identifiable and unified administrative and functional structure as determined by the Department.
Participating coordinated care provider—A provider who is employed by a CCO or a CCO affiliate or who has entered into an agreement or contract with a CCO, and who provides treatment, accommodations, products or health services to injured workers pursuant to that relationship.
Primary medical services—The following services frequently utilized by injured workers:(i) Inpatient hospital medical surgical services.
(ii) Hospital emergency room or urgent care center services.
(iii) Primary care physician—family practitioner or general internal medicine—services.
(iv) Diagnostic imaging facility services.
(v) Inpatient and outpatient physical therapy and rehabilitation services.
(vi) Rehabilitation medicine specialist services.
(vii) Orthopedic specialist services.
(viii) General surgery specialist services.
(ix) Ophthalmology specialist services.
(x) Chiropractic services.
(xi) Neurological specialist services.
(xii) Mental health professional services.
Single service referral, provider participation and payment agreement—A combined referral form and provider agreement utilized by a CCO to refer an injured worker to a provider who has not entered into a general contract or agreement with the CCO to treat the injured workers referred by the CCO.
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