SubPart 732-1 - Provider certification

Effective Date: 
Wednesday, July 16, 1997
Doc Status: 
Complete
Statutory Authority: 
Workers' Compensation Law, Article 10-A

Section 732-1.1 - Definitions

Section 732-1.1 Definitions. The following terms, as used in this Part, shall have the following meanings:

(a) "Carrier" or "insurer" shall mean the insuring, risk bearing entity which contracts with the employer and the PPO for the provision of workers' compensation medical and service benefits.

(b) "Chair" shall mean the Chair of the Workers' Compensation Board

(c) "Claimant" shall mean an individual employed by or otherwise covered for workers' compensation benefits by a participating employer and eligible for medical care provided by a PPO who receives treatment for or applies for medical and/or health services for any accidental injury arising out of and in the course of employment or for occupational disease.

(d) "Commissioner" shall mean the Commissioner of Health.

(e) "Emergency or urgent care" shall mean medical care, treatment, services, products or accommodations provided to an injured or ill employee for a sudden onset of a medical condition of such nature that failure to render immediate care would reasonably result in deterioration of the injured employee's medical condition.

(f) "Governing body" shall mean the board of directors or trustees of a not-for-profit corporation, the officers, directors and stockholders of a business corporation, all partners in a partnership or the individual proprietor of a PPO.

(g) "Preferred Provider Organization" or "PPO" shall mean a plan certified pursuant to the requirements of this Subpart owned, operated or administered by an entity that provides or arranges for the coordination and delivery of all services required by subdivision (h) of this section to all persons covered by such plan. No insurer or employer shall have any financial interest in the PPO.

(h) Services provided by a PPO shall include all services provided or arranged for under the Workers' Compensation Law to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or an accidental injury arising out of and in the course of employment, which shall include but not be limited to:

(1) inpatient hospital services;

(2) emergency or urgent care services;

(3) primary care physician services;

(4) diagnostic imaging services;

(5) physical therapy, occupational therapy and rehabilitation services;

(6) other therapeutic services;

(7) mental health professional services;

(8) pharmacy services;

(9) specialist services as required by patient conditions and/or authorized under the Workers' Compensation Law.

(10) occupational disease and injury services; and

(11) such other services as may be required by the commissioner to be provided as a condition of certification.

(i) "Service area" shall refer to an area defined on a county by county basis.

(j) "Employer" shall mean an employer covered by the Workers' Compensation Law who is either self-insured or who contracts with an insurer to arrange for coverage for employees for all necessary treatment and care for accidental injury, illness arising out of and in the course of employment or for occupational disease.

(k) "Rural area" shall mean any county not defined as an urban area pursuant to this section.

(l) "Urban area" shall, for the purposes of this Part, mean the following counties: Albany, Bronx, Broome, Chautauqua, Chemung, Dutchess, Erie, Kings, Monroe, Montgomery, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Oswego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Suffolk and Westchester.

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

Section 732-1.2 - Preferred Provider Organization Certification

732-1.2 Preferred Provider Organization Certification.

(a) Any plan, owned, operated or administered by an entity which has the capacity to establish a network of service providers to coordinate and provide all services provided or arranged for under the workers' compensation law to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or accidental injury arising out of and in the course of employment, as enumerated in paragraphs (1) to (11) of subdivision (h) of section 732-1.1 of this Subpart and to meet the operating standards established in Subpart 732-2 of this Part may apply to the commissioner for certification as a PPO. Such application shall be on forms provided by the Department of Health and shall be accompanied by a $500 application fee.

(b) Each application for certification as a PPO shall include the following information:

(1) the standards by which the providers participating in the preferred provider organization will be selected;

(2) the names and credentials of all individuals and organizations, and certifications of all hospitals, that will provide service under the preferred provider organization, together with appropriate evidence of workers' compensation board authorizations for such individuals as well as evidence of compliance with all licensing or certification requirements for such individuals or organizations to practice in this State;

(3) a description of any final disposition of professional misconduct charges against any of the individuals or organizations which will provide medical or other health care services under the preferred provider organization program;

(4) a description of the times, places and manner of providing service under the preferred provider organization;

(5) a detailed description of procedures to be followed in meeting the requirements of Subpart 732-2 of this Part for ongoing quality assurance, service utilization review and dispute resolution; including:

(i) procedures for implementing the internal dispute resolution protocol described in paragraph (1) of subdivision (h) of section 732-2.2 of this Part;

(ii) for disputes not resolved through the internal dispute resolution process, a process for determining whether and how to access the Workers' Compensation Board dispute resolution process described in paragraph (2) of subdivision (h) of section 732-2.2 of this Part;

(6) if incorporated, a copy of the applicant's certificate of incorporation, bylaws and, if applicable, certificate of doing business under an assumed name;

(7) if not incorporated, a copy of the applicant's proposed certificate of incorporation, bylaws, partnership agreement, application for authority to do business in New York, and certificate of doing business under an assumed name, as applicable;

(8) a description of the projected service area;

(9) a description of how access to services will be provided to claimants who reside outside the proposed service area;

(10) a description of how the PPO will ensure that at least five medical or health care providers will be made available in each county to claimants in each area of specialization required or offered, OR:

(i) documentation indicating that there are not at least five physicians in a particular specialty in each county within the service area; and

(ii) documentation indicating that there are at least five of the following specialty physicians under contract within each county within the proposed service area: family practice (board certified GP); orthopedic surgery, neurology, internal medicine; physical therapist; chiropractor and surgeon; and

(iii) documentation indicating that there are at least five of the following specialty physicians under contract within a county or counties contiguous to one or more of the other counties which comprise the service area: anesthesiology, physical medicine and rehabilitation; psychiatry; psychology; radiology and dermatology; and

(iv) documentation indicating that there are at least five of the following specialty physicians under contract within the Workers' Compensation Board District Office service area: cardiology; pulmonary disease; ophthalmology; hand surgery; pathology; plastic surgery; urology; podiatrist; occupational therapist, neurological surgery; otolaryngology; thoracic surgeon; allergy and immunology; or

(v) documentation indicating that the standards contained in subparagraphs (i)-(iv) of this paragraph cannot be met along with documentation, acceptable to the chair, in consultation with the commissioner, indicating how the PPO will provide claimants with an equivalent and accessible choice of practitioners;

(11) a description of how the PPO will ensure that a claimant will be able to choose from at least three hospitals within a radius appropriate to the care needs of claimants in the event that hospitalization is necessary; provided that: (i) for urban counties, there shall be at least one hospital available within the county and at least two other hospitals available in counties other than such urban county, which are within the Workers' Compensation Board District Office service area; and

(ii) for rural counties, where there is no hospital affiliated with the PPO within a travel distance from either the work site or claimant's home of forty miles or less, the PPO shall permit the claimant to be treated at the hospital nearest to either the claimant's worksite or home that has the capability to treat the claimant's condition, and shall reimburse such hospital at the established diagnosis related group reimbursement rate, or as otherwise authorized by law;

(12) an independently audited financial statement of the current financial condition of the applicant; and

(13) such other information relating to the certification and operation of the PPO as the commissioner may deem necessary.

(c) An applicant shall demonstrate, to the satisfaction of the commissioner, that the medical director and the members of the board, officers, controlling persons of a corporation, the owners, including individuals, shareholders, and all of the partners of a partnership, are of such character, experience, competence and standing in the community as to give reasonable assurance of their ability to conduct the affairs of the proposed PPO in the best interest of the PPO and in the public interest, and to provide proper care for claimants.

(1) In determining the character and competence of the foregoing individuals and controlling person(s), the commissioner shall consider matters including, but not necessarily limited to, criminal convictions, bankruptcy proceedings, and the quality of health-related services provided by such individuals and controlling person(s) and any facility or organization which is or has been affiliated or related to the PPO or its controlling person(s) or with which any officer, member of the board, controlling person, owner, partner or medical director is or has been affiliated. Such determination shall also identify and proscribe any financial interest by the insurer or employer in the PPO.

(2) If a controlling person is an entity already certified by the Department of Health to provide care and services, such entity may not be required to undergo as extensive a character and competence review as a controlling person not so certified.

(d) An applicant shall provide to the commissioner a list of all individuals comprising the governing body with current mailing addresses. An applicant shall demonstrate to the satisfaction of the commissioner that such governing body shall be responsible for establishment and oversight of the PPO's policies, management and overall operation, including responsibility for adoption and enforcement of all policies governing the PPO's management, contracting, health care services delivery, quality assurance and improvement and utilization review programs and all other PPO operations.

(e) The commissioner shall not certify an applicant to operate as a PPO until such applicant has satisfied the commissioner that the application is complete and that the applicant satisfies the criteria set forth in this section and Article 10-A of the Worker's Compensation Law. The commissioner shall review and act upon any complete application within 90 days of receipt of such application.

(f) In the event of a refusal to certify, the commissioner shall provide the applicant with a detailed written statement of the basis or bases for such refusal.
 

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

Section 732-1.3 - Change in ownership or control of Preferred Provider Organization.

732-1.3 Change in ownership or control of Preferred Provider Organization. The governing body shall provide the commissioner with written notice of any proposed change in the ownership or control of the entity certified to operate as a PPO. If such change requires the prior approval of any other agency, board or officer of this state, or any other state or jurisdiction, the governing body shall provide the commissioner with documentation of such other entity's determination to approve or disapprove such proposed change. No change shall be implemented prior to approval thereof by the commissioner pursuant to the applicable provisions of this Subpart for initial certification and the commissioner shall not issue such approval if the change in ownership results in the insurer or employer having a financial interest in the PPO.
 

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

Section 732-1.4 - Preferred Provider Organization Decertification

732-1.4 Preferred Provider Organization Decertification.

(a) The commissioner may revoke, suspend or amend the certification of any PPO if the commissioner finds that:

(1) the PPO fails to meet any of the requirements of this Part or Article 10-A of the Workers' Compensation Law, or fails to maintain compliance with the standards set forth in the application for certification.

(i) If the commissioner has reason to believe that such lack of compliance was unintentional and did not have a negative impact on any claimant, he or she may request from the PPO a plan of correction; and

(ii) if such plan of correction is accepted by the Commissioner and implemented, decertification shall not be required; or

(2) the PPO has knowingly provided false or misleading information in its application for certification.

(b) Decertification of a PPO shall preclude the organization and its principals from operating or being affiliated in any manner with a PPO certified pursuant to this Part for a period of not less than three years from the date of decertification.

(c) If the commissioner has reason to believe a medical or other health care provider or physician participating in a certified PPO fails to meet the requirements of Article 10-A of the Workers' Compensation Law or regulations promulgated pursuant thereto, he/she shall promptly provide information and documentation concerning such belief to the chair.

(d) The chair shall notify the commissioner of any providers disqualified from the PPO network under the Worker's Compensation Law.
 

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