Part 732 - Workers' Compensation Preferred Provider Organizations

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

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

SubPart 732-2 - Operations

NOTE: A PPO shall arrange for or provide to claimants services for the diagnosis, treatment and rehabilitation of any accidental injury arising out of and in the course of employment and for occupational disease in accordance with claimant needs. Such care and treatment shall meet generally accepted professional standards and shall be provided by health care professional who are currently licensed, registered or certified as appropriate and are employed by or under contract with the PPO.

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

Section 732-2.1 - Organization and administration

Section 732-2.1 Organization and administration.
(a) The PPO shall have a governing body functioning in accordance with the provisions of subdivision (d) of section 732-1.2 of this Part.
(b) The PPO shall employ an administrator who shall be responsible for overseeing all facets of the operation.
(c) The PPO shall employ a medical director responsible for oversight of all aspects of medical care including the quality and appropriate utilization of services and the development, updating and assurance of compliance with medical standards. Individuals providing medical direction shall have training and experience necessary for effective performance and any such individuals who practice medicine in New York State shall comply with licensing, registration and scope of practice requirements of the State Education Department. Medical direction shall also be provided consistent with the requirement that the insurer or employer shall not have a financial interest in the PPO.
 

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

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

Section 732-2.3 - Quality assurance and improvement

732-2.3 Quality assurance and improvement.

(a) A PPO shall develop and implement on a continuous basis a quality assurance and improvement program that includes organizational arrangements and ongoing procedures for the identification, evaluation and resolution of potential and actual problems in health care administration and delivery to claimants. These organizational arrangements and ongoing procedures shall be fully described in written form, provided to all members of the governing authority, providers and staff, and made available to eligible employees of an affected employer.

(b) The organizational arrangements for the quality assurance and improvement program must be clearly defined and should include, but need not be limited to, the following:

(1) a quality assurance and improvement committee, responsible for quality assurance activities, consisting of the medical director, the administrator, at least one member of the governing body and provider representatives including physicians;

(2) accountability of the committee to the governing body, with requirements for periodic written and oral reports to the governing body;

(3) participation from an appropriate base of providers and support staff;

(4) supervision by the medical director;

(5) regularly scheduled meetings at appropriate intervals but at least quarterly; and

(6) written minutes of the meetings of the quality assurance and improvement committee describing in detail the actions taken by the committee, the medical charts reviewed, problems discussed, recommendations made, and any other pertinent discussions and activities.

(c) The content of the quality assurance and improvement program shall reflect the scope of services provided and address all of the following:

(1) high risk procedures;

(2) sentinel events or occurrences; screens to identify potential failures in quality of care;

(3) development of explicit criteria and protocols for evaluating the quality of care;

(4) review and documentation of all claimant complaints and written evaluations described in paragraph (12) of subdivision (e) of section 732-2.6 of this Subpart and reasons given by those who opt out. Such written evaluations from claimants and any data extracted from such forms shall be made available to the commissioner and chair upon request;

(5) review and assessment of the continuity of care;

(6) review and assessment of the appropriateness and timeliness of referrals;

(7) review of the education and training of all primary treating physicians to ensure their knowledge and training in occupational medicine and Workers' Compensation Law requirements, including but not limited to:

(i) regulatory and reporting requirements under the workers' compensation program; and

(ii) familiarity with workplace hazard causes, restrictions, disability evaluation and rehabilitation; and

(8) review of the adequacy of access to care as demonstrated by records of complaints pertaining to waiting periods for appointments and telephone access.

(d) A PPO shall document the manner by which it examines actual and potential problems in health care administration and delivery to eligible employees. While a variety of methods may be utilized, the following components shall be addressed:

(1) the establishment of procedures for the analysis, monitoring and assessment of the quality of care provided, including review criteria developed in accordance with generally accepted standards of medical practice;

(2) the acquisition of sufficient data to perform a meaningful analysis; for example, through a statistically valid sample size for medical chart review; and

(3) involvement of appropriate clinical personnel, including physicians and other providers, in peer review activities.

(e) The quality assurance and improvement program shall include the development and documentation of timely and appropriate recommendations for addressing problems that are identified in health care administration and delivery to claimants. The PPO shall demonstrate operational mechanisms for responding to those problems.

(f) The PPO shall document the steps taken to follow-up on recommendations made by the quality assurance and improvement committee. The PPO shall be able to demonstrate that recommendations of the committee responsible for quality assurance activities are reviewed and acted upon in a timely manner, in order to:

(1) assure the implementation of appropriate action relative to the recommendations;

(2) assess the results of such action; and

(3) provide for revision of recommendations or actions and continued monitoring when necessary.
 

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

Section 732-2.4 - Reimbursement

732-2.4 Reimbursement.

(a) A PPO shall not be required to reimburse for provider services in accordance with the provider fee schedules authorized pursuant to the Workers' Compensation Law.

(b) PPOs shall be eligible for reimbursement on a fee-for-service basis.
 

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

Section 732-2.5 - Contracts

732-2.5 Contracts.

(a) PPOs shall have written contracts with all providers in the network.

(1) Such contracts shall be made available for review by the commissioner upon request.

(2) The PPO shall develop and, upon request, make available to prospective providers, written application procedures and minimum qualification requirements which the provider must meet in order to be considered by the PPO.

(3) Unless otherwise specified in contract, a PPO shall not terminate a contract with a provider unless it gives the provider a written explanation of the reasons for the proposed termination and an opportunity for a review or hearing. Either party to a contract, however, may, on sixty day notice, exercise a right of non-renewal at the expiration of the contract period or, for a contract without a specific expiration date, on each January first occurring after the contract has been in effect for at least one year. Such non-renewal shall not constitute a termination.

(4) Unless otherwise specified in contract, a provider may not terminate a contract with a PPO except upon a material breach of contract by the PPO. Such terminations shall be reported to the chair and shall take effect only after arrangements for the continuing care of affected claimants, acceptable to the commissioner and such claimants, are effected.

(b) A PPO may enter into a management contract with an entity to oversee the management of the day to day activities of the PPO with respect to the performance of various services including: management information systems, utilization review, payment and medical dispute resolution and quality assurance. However, a PPO may not enter into a management contract with a self-insured employer, an insurance carrier or with any entity owned or controlled by, or affiliated with such carrier to oversee the management of the day to day activities of the PPO with respect to the performance of the following services: quality assurance and medical dispute resolution. Any such contract shall be effective only with the prior written consent of the commissioner, and shall include the following:

(1) a description of the proposed role of the PPO governing authority during the term of the proposed management contract. The description shall clearly reflect retention by the governing authority of the PPO of ongoing responsibility for statutory and regulatory compliance;

(2) a provision that clearly recognizes that the responsibilities of the governing authority of the PPO are in no way obviated by entering a management contract, and that any powers not specifically delegated to the management contractor through the provisions of the contract remain with the governing authority of the PPO;

(3) a clear acknowledgement of the authority of the commissioner to terminate the contract, when a determination is made that the PPO is not providing adequate care or otherwise assuring the health, safety and/or welfare of the claimants;

(4) a provision that annual reports on the financial operations and any other operational data requested by the governing authority of the PPO, the commissioner or chair, will be provided by the management contractor;

(5) a provision stating that the management contract approved by the department shall be the sole agreement between the management contractor and the governing authority of the PPO for the purpose of management of the PPO and payment to the management contractor for management services, and that any amendments or revisions to the management contract shall be effective only with the prior written consent of the commissioner; and

(6) specification of payment terms that are reasonable and do not jeopardize the financial security of the PPO.
 

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

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

Section 732-2.7 - Notice and approval required to discontinue operation

732-2.7 Notice and approval required to discontinue operation.

(a) No PPO shall voluntarily discontinue operation unless at least 90 days written notice of its intention to do so is sent to each participating carrier or self-insured employer, the commissioner and the chair. Such entities shall communicate this information to other affected employers.

(1) Operations shall not be discontinued until approval to do so is obtained from the commissioner.

(2) The commissioner shall grant such approval when the conditions of subdivision (b) of this section have been met.

(b) A PPO discontinuing operations for any reason, including decertification, shall, preceding discontinuance:

(1) notify the commissioner in writing and make arrangements, subject to the approval of the commissioner, to maintain, store, assure access to and make available upon request, all clinical records for a period of not less than six years after completion of treatment or, for a minor, six years after reaching the age of majority;

(2) provide a written plan, acceptable to the commissioner, for the continuation of care for each claimant; and

(3) comply with all requirements established by the commissioner in any order of decertification.
 

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