(a) HCOs must demonstrate that they meet the
following requirements:
(1) All facilities
located in this state including, but not limited to, clinics, hospitals,
laboratories, and skilled nursing facilities to be utilized by the HCO for the
delivery of occupational medical and health care services or other services
specifically required by this article shall be licensed by the State Department
of Health Services, if such licensure is required by law, and shall meet any
other relevant certification requirements. Facilities not located in this state
shall conform to all licensing and other requirements of the jurisdiction in
which they are located.
(2) All
personnel employed by or under contract to the HCO shall be licensed or
certified by their respective board or agency, where such licensure or
certification is required by law.
(3) All equipment required to be licensed or
registered by law shall be so licensed or registered and the operating
personnel for such equipment shall be licensed or certified as required by
law.
(4) The HCO shall provide
continuity of care and timely referral of patients to other providers in a
manner consistent with professionally recognized standards of care.
(5) All services shall be available and
accessible at reasonable times to all HCO enrollees.
(6) The HCO may employ and utilize allied
health personnel for the furnishing of occupational health services to the
extent permitted by law and provided such use is consistent with professionally
recognized standards of care; however, any course of treatment beyond first
aid, as defined in subdivision (c) of Section
14311, shall provide for at least
one face to face visit with a primary treating physician.
(7) The HCO shall have the organizational,
financial, and administrative capacity to provide services to employers, claims
administrators, and HCO enrollees. The HCO shall be able to demonstrate to the
Division that medical decisions are rendered by qualified providers unhindered
by fiscal and administrative management, and that such decisions adhere to
professionally recognized standards of care.
Any applicant that is owned in whole or in part or
controlled by a workers' compensation insurer or self-insured employer shall,
in addition to the requirements set forth above, further demonstrate that the
organization's claims function shall have no influence or control over medical
decision-making. The applicant shall further demonstrate that the clear
authority of its Medical Director over all medical decisions is reflected both
in its organizational chart and any internal procedure manual or other internal
description of HCO operations.
(8) All contracts with claims administrators,
employers, providers and other persons or entities furnishing services
specifically required by this article shall be consistent with the requirements
of this article and Division 4 of the Labor Code.
