34 Pa. Code § 122.612 - Standards for utilization review
(a)
A CCO shall have an organized system for the review of the utilization of
services rendered by the CCO and its participating coordinated care providers
to injured workers to avoid the provision of poor quality care to injured
workers which may arise from either underutilization or overutilization of
services. A CCO may engage in prospective, concurrent or retrospective review
without obtaining a separate approval from the Department of Labor and Industry
as a utilization review organization, subject to the following conditions:
(1) The CCO shall place responsibility for
compliance with utilization review requirements, particularly precertification
requirements, upon its participating coordinated care providers and not upon
injured workers.
(2) The CCO shall
prohibit participating coordinated care providers from collecting payment from
injured workers for care provided by the provider but rejected for payment by
the CCO and the payor as being medically unnecessary, or for a financial
penalty or fee reduction imposed on the provider due to its failure to follow
CCO precertification requirements.
(3) The CCO shall conduct utilization review
on treatment provided to an injured worker only for the 30-day period it is
entrusted with treatment of the injured worker by virtue of the injured worker
having initially selected the CCO from the health care provider list offered by
the employer under section 306(f.1)(1)(i) of the act (77 P. S. §
531.1(1)(i)), and during the
time that the injured worker continues to utilize the CCO for treatment of the
work-related injury.
(4) The CCO
shall have an adequate procedure for a participating coordinated care provider
dissatisfied with the initial utilization review decision to appeal that
decision. An injured worker dissatisfied with an initial utilization review
decision shall have the right to appeal that decision through the grievance
process.
(5) The CCO shall make
decisions regarding pretreatment certification and appeals from utilization
review decisions within 7 days of the request and provide notice of its
decision to the provider and injured worker.
(6) The CCO shall do the following:
(i) Maintain a written record of staffing
within its utilization review system; the professional experience of the staff;
staffing to injured worker ratios; and the basis and source of the criteria,
standards and guidelines the CCO uses in conducting utilization and return to
work case management review.
(ii)
Disclose to its participating coordinated care providers its utilization review
criteria, standards and guidelines.
(iii) Make available its utilization review
criteria, standards and guidelines to injured workers utilizing the CCO, their
employers and workers' compensation insurers.
(iv) Utilize qualified and experienced
registered nurses to make initial utilization review decisions.
(v) Base treatment or service denials on the
clinical review by a qualified physician or practitioner of the service under
review.
(b) If
the CCO, rather than performing utilization review itself or by an affiliate
under common ownership and control, contracts with an independent utilization
review organization, the utilization review organization shall be one which has
been approved by the Department of Labor and Industry and has entered into a
contract with the CCO in accordance with §
122.626 (relating to contracts
with independent organizations for performance of case management and
communication or utilization review services).
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