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34 Pa. Code § 122.612. Standards for utilization review.

§ 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).

Cross References

   This section cited in 34 Pa. Code §  122.603 (relating to uncertified CCOs); and 34 Pa. Code §  122.608 (relating to contents of an application for certification as a CCO).

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