Section 732-2.6 - Records, reports and information requirements

732-2.6 Records, reports and information requirements.

(a) Clinical records shall be made available for review by the commissioner and otherwise afforded confidentiality in accordance with applicable state law, including laws on confidentiality of HIV records, and unwarranted access shall be prevented.

(b) The PPO shall report to the commissioner information regarding disciplinary action against any provider or information regarding professional misconduct.

(c) All other business records and data maintained by the PPO, and relevant to the commissioner's authority to oversee the activities of the PPO and to determine the appropriateness of continued certification, either pursuant to applicable law or in the normal conduct of business, shall be made available to the commissioner and/or chair upon request.

(d) The PPO shall develop a detailed plan for providing affected employees with written notice of the PPO arrangement for the treatment of all workers' compensation injuries and illnesses. Such written notice shall also advise potential claimants where they may obtain a handbook which contains written information about the PPO as described in subdivision (e) of this section.

(e) The PPO shall develop a handbook, a limited number of which shall be distributed by an appropriate party to all participating employers, upon the entering of a contract between the PPO and the carrier. The handbook shall be written in an understandable manner. Employers will be expected to reproduce the handbook in sufficient numbers to provide copies to employees on an as-needed basis. The handbook shall contain:

(1) all information needed by an employee to access services and programs offered by the PPO, including 24 hour emergency care;

(2) the procedures for selecting and changing providers within the PPO network;

(3) a full explanation of all rights and responsibilities of the PPO, employer and employee when services are required;

(4) a detailed description of the policies and procedures of the PPO including service utilization review policies and procedures;

(5) the manner in which medical determinations are made in the PPO/workers' compensation area;

(6) a listing of all participating providers, including address and telephone number, their specialties, any board certification and the means of initiating contact;

(7) a description of how such providers are reimbursed;

(8) a description of the process for obtaining a second opinion, which the claimant may seek from another provider within the PPO at any time, with respect to a proposed medical treatment;

(9) a description of the process for opting out of PPO care which shall include:

(i) the right of the claimant to seek medical treatment from outside the PPO thirty days after his or her first visit to a PPO provider; and

(ii) the right of an employer to require, under such circumstances, a second opinion from a provider within the PPO;

(10) a description of how the PPO addresses the needs of non-English speaking claimants;

(11) the procedure for filing grievances against the PPO, the location and/or phone number where grievances may be filed and the procedure for processing and resolving grievances;

(12) a description of the process by which claimants may participate in a written evaluation of the PPO and thereby influence changes in policies and procedures;

(13) the procedure for filing a complaint with the workers' compensation board and/or the Department of Health;

(14) the procedure for obtaining a referral to the New York State Occupational Health Clinics Network when the claimant chooses to obtain treatment at such clinics for occupational disease; and

(15) general claimant education material which will assist the claimant in obtaining care.

(f) If a provider ceases participation in the PPO, or if any provider becomes unavailable to provide services to any claimant, the PPO shall provide written notice to affected claimants within fifteen days from the date that the organization becomes aware of such change in status. Such notice shall also describe:

(1) the procedures for choosing an alternative provider within the PPO network; and

(2) steps to be taken to ensure that medically appropriate continuity of care for the claimant is maintained.
 

Effective Date: 
Wednesday, July 16, 1997
Doc Status: 
Complete