Section 732-2.2 - General operating requirements

732-2.2 General operating requirements.

(a) The PPO shall develop, implement, require provider adherence to and make available for inspection by the commissioner quality and treatment standards and protocols, consistent with generally accepted standards of care, which will ensure the coordination, quality and continuity of care for claimants.

(b) The PPO shall ensure that emergency and urgent care are available and accessible to claimants twenty-four hours a day, seven days a week. However, a claimant may access any medical facility during an emergency or urgent care situation.

(c) The PPO shall ensure that first access to initial treatment for all non-emergency care is available to injured employees within 48 hours of a request by a claimant for treatment for any accidental injury arising out of and in the course of employment or for occupational disease and that subsequent referrals are made on a timely basis.

(d) If the PPO cannot provide access to necessary services within the approved provider network within 48 hours of a claimant's request, it shall secure such services from appropriate practitioners outside the approved network within 48 hours of a claimant's request and bear the cost of such services.

(e) The PPO shall develop and implement a system under which employees may obtain information on a 24 hour-a-day basis regarding the availability of necessary medical services including emergency services and other urgently needed medical care.

(f) The PPO shall submit to the commissioner and ensure the conduct of a service utilization review process which indicates what reports are to be produced, the frequency of review, the standards used and the types of corrective action to be taken when problems are identified. Such process shall:

(1) be consistent with the utilization review requirements of Article 49 of the State Insurance Law, Article 49 of the Public Health Law or a generally accepted and nationally recognized utilization review accrediting entity acceptable to the Commissioner; or

(2) be produced by an entity currently certified by the Utilization Review Accreditation Commission.

(g) The PPO shall submit to the commissioner a detailed description of the procedures to be followed for dispute resolution which shall include access to a second opinion for the claimant from another provider within the PPO at any time. The PPO shall comply with such procedures.

(h) The PPO shall submit to the commissioner and implement a grievance procedure consistent with applicable law. Such process shall address the objective and equitable resolution of disputes between the PPO and the employer and the PPO and the insurer.

(1) Grievances and/or disputes which arise between the PPO and the claimant may be handled in accordance with the internal dispute resolution protocol which shall comply with section 4408-A and Article 49 of the Public Health Law, as applicable. The internal dispute resolution protocol shall also address the resolution of disputes between the claimant and any PPO providers, providers and the insurer, the PPO and any providers and the PPO and the insurer.

(2) If a dispute is not resolved through the internal dispute resolution protocol, the parties may avail themselves of the remedies provided by sections 13-g, 13-k, 13-1 and 13-m of the Workers' Compensation Law. Notwithstanding the other requirements of this subdivision regarding the PPO's internal dispute resolution protocol, insurers, providers and PPOs wishing to protect their right to dispute resolution in accordance with this paragraph shall continue to have the right to file notice with the workers' compensation board in accordance with the timeframes established in sections 13-g, 13-k, 13-l and 13-m of the Workers' Compensation Law and have such disputes resolved in accordance with such laws.

(i) Consistent with all applicable statutes regarding the confidentiality of patient medical records, only the PPO shall have access to patient medical records maintained by network providers. The PPO shall provide any information required by the commissioner, the chair and/or the workers' compensation board including evidence of compliance with all regulatory requirements and representations made in the application for certification, on a timely basis and shall provide truthful testimony and supporting documentation including accurate and complete patient medical records to the workers' compensation board, as required by such board, on a timely basis and in accordance with applicable statute and regulation.

(j) An injured employee may continue to receive necessary care for a pre-existing condition in any compensation case from a non-PPO network provider who has been providing ongoing treatment to such employee for the specific work-related injury or illness. Such provider must be authorized pursuant to the workers' compensation law to provide such care. (k) The PPO shall make claimants aware of their right to opt out of PPO care, which shall include:

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

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

(l) The PPO shall not, by contract, written policy, or written procedure:

(1) prohibit or restrict any provider from disclosing to any claimant or designated representative any information that such provider deems appropriate regarding a condition or course of treatment;

(2) prohibit or restrict any provider from filing a complaint, making a report, or commenting to an appropriate governmental body regarding the policies or practices of the PPO which the provider believes may negatively impact upon the quality of, or access to, claimant care;

(3) prohibit or restrict any provider from advocating to the PPO on behalf of a claimant for a particular course of treatment; or

(4) purport to transfer to the provider, by indemnification or otherwise, any liability relating to activities, actions or omissions of the PPO as opposed to those of the provider.

(m) The PPO shall permit the claimant to choose to obtain treatment for occupational diseases from the New York State Occupational Health Clinics Network. Such treatment shall be specific to the claimant's occupational disease and all other care shall be provided by the PPO.

(n) The PPO shall maintain a return-to-work program in conjunction with the employer, treating physician and carrier to facilitate the return of injured workers to the workplace.
 

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