STATE OF CONNECTICUT WORKERS COMPENSATION COMMISSION EMPLOYER MEDICAL CARE PLANS INFORMATION PACKET

Transcription

1 STATE OF CONNECTICUT WORKERS COMPENSATION COMMISSION EMPLOYER MEDICAL CARE PLANS INFORMATION PACKET Enclsed are infrmatinal materials n wrkers cmpensatin emplyer medical care plans in the State f Cnnecticut. Please reference Cnnecticut General Statute and Administrative Regulatin , fr a listing f the infrmatin required in a medical care plan applicatin. A checklist has been prvided t assist yu. Shuld yu have any questins, please cntact Marilu O. Lang r Elaine Silver at (860)

2 Please be advised that the statute which grants authrity fr wrkers cmpensatin medical care plans is Cnnecticut General Statute , subsectins (c) and (d). Sec Ntice f availability f cmpensatin. Unifrm system fr determinatin f degree f physical impairment. Emplyer-spnsred plan fr medical care and treatment. Indemnificatin f medical advisry panel members. (c) (1) Any emplyer r any insurer acting n behalf f an emplyer, may establish a plan, subject t the apprval f the chairman f the Wrkers Cmpensatin Cmmissin under subsectin (d) f this sectin, fr the prvisin f medical care that the emplyer prvides fr treatment f any injury r illness under this chapter. Each plan shall cntain such infrmatin as the chairman shall require, including, but nt limited t: (A) A listing f all persns wh will prvide services under the plan, alng with apprpriate evidence that each persn listed has met any licensing, certificatin r registratin requirement necessary fr the persn t legally prvide the service in this state; (B) A listing f all pharmacies that will prvide services under the plan, t which the emplyer, any insurer acting n behalf f the emplyer, r any ther entity acting n behalf f the emplyer r insurer shall make direct payments fr any prescriptin drug prescribed by a physician participating in the plan; (C) A designatin f the times, places and manners in which the services will be prvided; (D) A descriptin f hw the quality and quantity f medical care will be managed; and (E) Such ther prvisins as the emplyer and the emplyees may agree t, subject t the apprval f the chairman. (2) The electin by an emplyee cvered by a plan established under this subsectin t btain medical care and treatment frm a prvider f medical services wh is nt listed in the plan shall suspend the emplyee s right t cmpensatin, subject t the rder f the cmmissiner. (d) Each plan established under subsectin (c) f this sectin shall be submitted t the chairman fr his apprval at least ne hundred twenty days befre the prpsed effective date f the plan and each apprved plan, alng with any prpsed changes therein, shall be resubmitted t the chairman every tw years thereafter fr reapprval. The chairman shall apprve r disapprve such plans n the basis f standards established by the chairman in cnsultatin with a medical advisry panel appinted by the chairman. Such standards shall include, but nt be limited t: (1) The ability f the plan t prvide all medical and health care services that may be required under this chapter in a manner that is timely, effective and cnvenient fr the emplyees; (2) the inclusin in the plan f all categries f medical service and f an adequate number f prviders f each type f medical service in accessible lcatins t ensure that emplyees are given an adequate chice f prviders; (3) the prvisin in the plan fr apprpriate financial incentives t reduce service csts and utilizatin withut a reductin in the quality f service; (4) the inclusin in the plan f fee screening, peer review, service utilizatin review and dispute reslutin prcedures designed t prevent inapprpriate r excessive treatment; and (5) the inclusin in the plan f a prcedure by which infrmatin n medical and health care service csts and utilizatin will be reprted t the chairman in rder fr him t determine the effectiveness f the plan.

3 STATE OF CONNECTICUT REGULATION OF WORKERS COMPENSATION COMMISSION Cncerning Medical Care Plans (a) All medical care plans submitted pursuant t Sectin f the Cnnecticut General Statutes by any emplyer r, n behalf f ne r mre emplyers, by any insurer, mutual emplyer assciatin, self-insurance service rganizatin r ther spnsring rganizatin t arrange fr the prvisin f medical and health care services, including medical and surgical aid r hspital and nursing service and medical rehabilitatin services, shall include the fllwing in additin t the infrmatin required by said sectin: (1) The identity f any cmpany r rganizatin which will participate in the peratin f the medical care plan, a descriptin f such participatin and, where applicable, the fllwing: (A) a certificate frm the Secretary f the State and/r the Insurance Cmmissiner regarding the cmpany r rganizatin's gd standing t d business in the State f Cnnecticut; (B) a cpy f the cmpany r rganizatin's balance sheet at the end f its mst recently cncluded fiscal year, alng with the name and address f any public accunting firm r internal accuntant which prepared r assisted in the preparatin f such balance sheet; (C) a list f the names, business addresses and fficial psitins f members f the cmpany r rganizatin's bard f directrs r ther plicymaking bdy and f thse executive fficers wh are respnsible fr the cmpany r rganizatin's activities with respect t the medical care plan; (D) a list f the cmpany r rganizatin's principal wners; (E) in the case f an ut-f-state cmpany r rganizatin, a certificate that such cmpany r rganizatin is in gd standing in its state f rganizatin; (F) the identity, address and current relatinship f any related r predecessr cmpany r rganizatin; related fr this purpse means that a substantial number f the bard r plicymaking bdy members, executive fficers r principal wners f bth cmpanies are the same; and (G) in the case f a Cnnecticut r ut-f-state cmpany r rganizatin, a reprt f the details f any suspensin, sanctin r ther disciplinary actin relating t such cmpany r rganizatin in this state r in any ther state. (2) A descriptin f the general financial arrangements between the emplyer, insurer, mutual emplyer assciatin, self-insurance service rganizatin r ther spnsring rganizatin and any cmpany r rganizatin participating in the peratin f the medical care plan, and a descriptin f the financial arrangements with the prviders f health care and medical services, including any fee schedule(s) r frmula(s) used t determine the fees f such prviders. T the extent permitted by law, the infrmatin required in this subdivisin shall be cnfidential and may be reviewed nly by the Chairman f the Wrkers' Cmpensatin Cmmissin r his designee. (3) A general descriptin f the medical care plan, including the respnsibilities f the fllwing: (A) the emplyer, insurer, mutual emplyer assciatin, self-insurance service rganizatin r ther spnsring rganizatin; (B) any cmpany r rganizatin identified in subdivisin (1) f subsectin (a); (C) prviders f health care and medical services; and Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins

4 (D) emplyees cvered under the plan. (4) Prvisin that such plan applies nly t illnesses r injuries incurred by emplyees cvered under the plan subsequent t the effective date f the medical care plan. (5) Prvisin that all medical and health care services that may be required within the service area identified by the plan shall be available at the ffices f participating prviders during regular r extended ffice hurs, and thrugh participating hspital emergency rms fr emergency cases which cannt be treated at the ffices f participating prviders during such regular r extended ffice hurs. The numbers and lcatins f such participating prviders, including hspital emergency rms, shall be such that care may be prvided immediately fr emergency cases, that an initial evaluatin and either apprpriate care r referral t ther plan prviders may take place within twenty-fur (24) hurs fr an injury r disease nt previusly treated which is nt an emergency case, and that ther necessary care will be prvided as apprpriate. With respect t hspital emergency rms and ther prviders f emergency care, the plan shall indicate its minimum criteria fr distance and/r travel time t such emergency care facilities frm the emplyer's principal emplyment lcatins. (6) A list f all emplyee and cntract prviders included within the plan; in the case f cntract prviders, their relatinships with the plan shall be described in a written agreement, a cpy f which shall be made available t the Chairman f the Wrkers Cmpensatin Cmmissin at his request. Said list f prviders shall be filed with the plan's applicatin fr apprval, updated fr changes at least quarterly and shall include: (A) at least ne ccupatinal health clinic, auxiliary ccupatinal health clinic r hspital that has a Bard Eligible r Bard Certified Occupatinal Health Physician. (B) at least three prviders (nt in the same grup r practice) r tw prviders (nt in the same grup r practice) with a minimum chice in ttal f five individual prviders f each f the fllwing types f medical and health care service: (i) Cardilgy; (ii) Chirpractic Medicine, (iii) Dentistry; (iv) Dermatlgy; (v) Family Practice; (vi) Gastrenterlgy; (vii) General Hspital Service; (viii) General Surgery; (ix) Internal Medicine; (x) Neurlgy; (xi) Neurlgical Surgery; (xii) Obstetrics and Gyneclgy; (xiii) Ophthalmlgy; (xiv) Optmetry; (xv) Orthpedic Surgery; (xvi) Otlarynglgy; (xvii) Physical Medicine and Rehabilitatin; (xviii) Physical Therapy; (xvix) Plastic Surgery; (xx) Pdiatry; (xxi) Psychiatry; (xxii) Psychlgy; (xxiii) Pulmnary Medicine; (xxiv) Radilgy; (xxv) Thracic Surgery; (xxvi) Urlgy; and (xxvii) Service frm such ther prviders f medical and health care service as determined by the plan t be necessary. Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins Page 2

5 (b) (7) A descriptin f the selectin criteria and remval prcedures fr prviders f medical and health care services under the medical care plan. This prvisin shall nt be cnstrued t require a medical care plan t accept all prviders wh apply fr participatin and meet the selectin criteria. T the extent permitted by law, the infrmatin required in this subdivisin shall be cnfidential and may be reviewed nly by the Chairman f the Wrkers Cmpensatin Cmmissin r his designee. (8) A written descriptin f the plan's review and appeal prcedures and standards fr service utilizatin review and dispute reslutin adpted pursuant t subsectins (e) and (h) f this regulatin. (9) A cpy f the infrmatin t be distributed t emplyees cvered by the medical care plan. This infrmatin shall be written in plain language and include the fllwing: (A) a descriptin f the medical care and treatment services available frm prviders f medical and health care services listed in the plan; (B) the manner in which the emplyee r his representatives may btain medical and health care services, whether frm plan prviders r ther prviders; (C) a descriptin f the prcedures by which an emplyee may questin r dispute the level f benefits paid under the plan; and (D) a detailed descriptin f an emplyee's right t btain medical care and treatment services frm a prvider f medical services wh is nt listed in the plan and the emplyee s financial and ther bligatins in the event the emplyee exercises this right. (10) A statement by the emplyer that an eligible emplyee's participatin in the medical care plan is nt incnsistent with any cllective bargaining agreement affecting such emplyee and that a cpy f the applicable cllective bargaining agreement will be made available t the Chairman n request. (11) In the case f an insurer, mutual emplyer assciatin, self-insurance service rganizatin r ther spnsring rganizatin, a statement that each emplyer whse emplyees are eligible t participate in the medical care plan has given written cnsent t such participatin and such written cnsent is in the insurer s, assciatin s r rganizatin s pssessin and will be made available t the Chairman n request. (12) Prvisin that a request made by an emplyee t be examined fr a secnd pinin by a reputable practicing physician r surgen nt listed in the plan shall be cnsidered reasnable and shall be paid fr by the emplyer if such request is submitted t and apprved by a Wrkers' Cmpensatin Cmmissiner. Fr these purpses, a reputable practicing physician r surgen shall be a physician r surgen n the apprved list f practicing physicians, surgens, pdiatrists and dentists established by regulatin. The Chairman may apprve plans which include emplyee r cntract prviders fr sme but nt all f the types f medical and health care service required by subparagraph (B) f subdivisin (6) f subsectin (a) f this sectin s lng as the fllwing requirements are satisfied: (1) the plan prvides t the emplyees the name, address and telephne number f each cntract and emplyee prvider f the plan; (2) fr each type f medical and health care service nt prvided by emplyee r cntract prviders, the plan shall clearly indicate that such service is available frm practitiners n the apprved list f practicing physicians, surgens, pdiatrists and dentists established by regulatin; (3) the plan cmplies with all ther requirements f this regulatin except, in the case f practitiners n the apprved list wh are nt emplyee r cntract prviders and wh are nt prviding medical and health care services pursuant Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins Page 3

6 (c) (d) (e) t an emplyee s electin t btain their services rather than the services f a plan prvider, the service utilizatin review and dispute reslutin prvisins f subsectin (e) shall nt apply. Medical care plans submitted n behalf f emplyers having twenty-five (25) r mre emplyees shall include a labrmanagement safety cmmittee fr each such emplyer with representatives f labr at least equal in number t representatives f management, in cmpliance with regulatins established by the Wrkers' Cmpensatin Cmmissin in Sectins 31-40v-1 thrugh 31-40v-11, unless such cmmittee representatin is incnsistent with a cllective bargaining agreement. Medical care plans submitted n behalf f emplyers having fifty (50) r mre emplyees shall include prvisin fr plan prviders t evaluate the capacity f injured emplyees f such emplyers t return t their mst recent emplyment, with r withut mdificatin, r t anther psitin with their emplyer. Such prviders shall indicate any limitatins n the ability f such emplyees t perfrm wrk related tasks. Each medical care plan shall include prvisin fr bth a service utilizatin review prviding a methd t evaluate the necessity and apprpriateness f medical and health care services recmmended by a prvider, and a means f dispute reslutin if payment fr such medical and health care services is denied. Such service utilizatin review and dispute reslutin shall include, at a minimum, the fllwing review and appeal prcedures: (1) Initiatin f a review by any ne r mre f the fllwing parties: the emplyee, the prvider, the emplyer, r the medical care plan itself, either directly r thrugh a utilizatin review cntractr. If a party ther than the plan initiates the review, such party shall supply t the plan all infrmatin in its pssessin which is relevant t the review. The plan may als request such infrmatin as it deems necessary t cnduct the review. (2) Upn receipt f all prffered and requested infrmatin, the plan shall review such recmmended treatment, utilizing written clinical criteria which have been established by the plan and peridically evaluated by apprpriate prviders f medical and health care services required under Chapter 568 f the Cnnecticut General Statutes. (3) Nt mre than tw (2) business days after receipt f all such infrmatin, the plan shall prvide written ntice t the prvider and emplyee f its determinatin regarding the recmmended treatment. Any written ntice f a determinatin nt t certify an admissin, service, prcedure r extensin f stay shall include the reasns therefr and the name and telephne number f the persn t cntact with regard t an appeal. The prvider and the emplyee shall als be prvided with a cpy f the written review and appeal prcedures. (4) The prvider r the emplyee may, within fifteen (15) days f the written ntice f determinatin, ntify the plan f his r her intent t appeal a determinatin t deny payment fr the recmmended treatment. (5) Upn such appeal, the plan shall prvide, at the request f the emplyee r prvider, a practitiner in a specialty relating t the emplyee's cnditin fr the purpse f reviewing the plan's initial decisin. (6) Within fifteen (15) days f the request fr such review and submissin f any further dcumentatin regarding the review, the reviewing practitiner shall submit his pinin regarding such recmmended treatment t the medical directr f the medical care plan wh shall, within fifteen (15) days thereafter, render a written decisin regarding such treatment. (7) The emplyee, the prvider r the emplyer may request a further review f the medical directr's written decisin; such request fr further review shall be in writing and shall be submitted t the chief executive fficer f the medical care plan within fifteen (15) days f the medical directr's written decisin. The party requesting further review shall have an pprtunity fr a hearing if such party requests it in writing and may, at such party's expense, prduce whatever written supprt r ral testimny it wishes at any such hearing. Such hearing shall be cnducted within fifteen (15) days f the written request therefr. The chief executive fficer f the medical care plan shall make any Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins Page 4

7 (f) (g) (h) final determinatin f such request fr further review and may utilize an advisry cmmittee t assist him in his determinatin. The chief executive fficer shall issue a final written decisin n the request fr further review as sn as practical but, in any event, within thirty (30) days f the later f the date f submissin f the written request fr such review r the date f cnclusin f the hearing requested as part f such review. (8) In the case f an emergency cnditin, an emplyee r his representative shall be prvided a minimum f twentyfur (24) hurs fllwing an admissin, service r prcedure t request certificatin and cntinuing treatment fr that emergency cnditin befre a utilizatin determinatin is made. If a determinatin is made nt t prvide such cntinuing treatment and the emplyee r his representative, the prvider, r the emplyer requests a review f such determinatin, an expedited review shall be cnducted by the medical directr and a final decisin rendered within tw (2) days f the request fr review. The necessity and apprpriateness f medical and health care services recmmended by prviders f a medical care plan shall nt be subject t review by a Wrkers' Cmpensatin Cmmissiner until the plan's utilizatin review and dispute reslutin review and appeal prcedures, as described in subsectin (e) have been exhausted. The decisin f the chief executive fficer f the plan relating t payment fr such medical and health care services shall be subject t mdificatin nly upn shwing that it was unreasnable, arbitrary r capricius. Each medical care plan shall include a quarterly reprt t the Chairman describing the result and number f appeals prcessed pursuant t the utilizatin review and dispute reslutin review and appeal prcedure set frth in subsectin (e). The service utilizatin review and dispute reslutin review and appeal prcedures f subsectin (e) shall, at a minimum, satisfy the fllwing standards: (1) Nurses and ther health prfessinals ther than physicians making utilizatin review recmmendatins and decisins shall hld current and valid licenses frm a state licensing agency in the United States. Physicians making utilizatin review recmmendatins and decisins shall hld current and valid licenses in the State f Cnnecticut. (2) Utilizatin review staff shall be generally available by tll-free telephne, at least frty hurs per week during regular business hurs. (3) Each utilizatin review prfessinal shall cmply with all applicable state and federal laws t prtect the cnfidentiality f individual medical recrds; summary and aggregate data shall nt be cnsidered cnfidential if it des nt prvide sufficient infrmatin t allw identificatin f individual patients. (4) All hspitals which are plan prviders shall permit licensed utilizatin review prfessinals t cnduct reviews n the premises. Each utilizatin review prfessinal shall cnduct its telephne and n-site infrmatin gathering reviews and hspital cmmunicatins during the hspitals reasnable and nrmal business hurs, unless therwise mutually agreed. Utilizatin review prfessinals shall identify themselves by name and by the name f their rganizatin, if any, and, fr n-site reviews, shall carry picture identificatin. (5) The prvider being reviewed shall prvide t each utilizatin review prfessinal, within a reasnable perid f time, all relevant infrmatin necessary fr the utilizatin review prfessinal t certify the admissin, prcedure, treatment r length f stay. Failure f the prvider t prvide such dcumentatin fr review shall be grunds fr a denial f certificatin in accrdance with the plicy f the utilizatin review rganizatin r medical care plan. (6) N utilizatin review prfessinal may receive any financial incentive based n the number f denials f certificatin made by such prfessinal. Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins Page 5

8 (i) (j) (k) (7) Any medical care plan which engages directly in utilizatin review and any utilizatin review cntractr which perfrms utilizatin review n behalf f a medical care plan shall, accrding t law, be licensed by the Cmmissiner f Insurance as a utilizatin review cmpany. Each medical care plan shall include a prcedure fr reprting infrmatin annually which prvides, at a minimum, the fllwing: (1) data cmparing emplyees treated under the medical care plan with emplyees treated utside the medical care plan, either because their illnesses r injuries were incurred befre the effective date f such plan r because they exercised their right t select their wn prviders utside the plan, and such cmparisns shall be made in terms f: (A) type f care; (B) vlume f care; (C) cst f care; and (D) lst time days per emplyee. (2) the number f emplyees wh began their treatment under the plan but subsequently sught treatment utside the plan, such data t be expressed bth in abslute numbers and as a percentage f the average emplyee plan ppulatin. Medical care plans may include, as a means f reducing service csts and utilizatin, the use f apprpriate emplyees r designated cntract prviders as care managers r crdinatrs; such care managers r crdinatrs shall be licensed, as required by law and as prvided in subsectin (h) f this regulatin and may have the fllwing duties: (1) T assist emplyees in btaining initial treatment and subsequent referrals t prviders f medical and health care services within the plan. (2) T mnitr the emplyee's prgress under the treatment plan designed fr that emplyee and make suggested changes r mdificatins in such treatment plan in the interests f quality care and cst-effective delivery f such quality care. (3) T cmmunicate apprpriately with the emplyer, insurer, self-insurance service rganizatin r ther claim administratr with respect t the emplyee's medical and health care treatment and recmmended payment therefr. Nthing in this sectin is intended t prhibit an emplyer frm prviding mre than ne medical care plan fr its emplyees, either directly r thrugh an insurer, mutual emplyer assciatin, self-insurance service rganizatin r ther spnsring rganizatin. Wrkers' Cmpensatin Cmmissin Medical Care Plan Regulatins Page 6

9 Administrative Regulatin Checklist Prpsed Effective Date: At least 120 days frm applicatin submissin Medical Care Plan Certificatin must be renewed every 2 years Medical Care Plan cvers nly thse injuries/illnesses incurred after effective date. Plan Organizatin: Plan Name Spnsr Name Type f business (insurer, TPA, mutual, emplyer, ther) State f incrpratin (attach Certificate f Gd Standing) Spnsr s balance sheet and accunting firm Bard f Directrs (names, psitins & respnsibilities) Principal wners and any predecessr r related cmpanies Any disciplinary actins? (attach reprt) Subcntractrs prviding plan peratin services: Fee Arrangements (Cnfidential) 1. Name & address f subcntractr 2. Certificate f Gd Standing 3. Descriptin f cntracted services Describe the plan s fee arrangements with emplyers, prviders & subcntractrs Attach fee schedule and frmulas used

10 Plan Respnsibilities Prvide a descriptin f the respnsibilities f each as relates t the peratin and participatin in the plan: Spnsr: Insurance Claims Persnnel Subcntractr(s) Licensed Case Managers Medical Directr, Chief Executive Officer Emplyer: Statement that plan participatin is nt in cnflict with any cllective bargaining agreement. Cpy f agreement t be available t Chairman n request. Descriptin f Mdified/Light Duty Wrk Prgram. Cpy f plain language explanatin t be distributed t emplyees. Hw and where services are available, penalty fr utside netwrk treatment. Safety Cmmittees in accrdance with CGS 31-40v. Attach names, titles, and addresses f cmmittee members. NOTE: Mre than ne plan per emplyer allwed. Medical Prviders: Agreement t fllw plan prcedures Prvisin fr Return t Wrk Evaluatin Emplyees: Methds fr reprting injury Mandatry treatment within the plan fr thse services cvered under an apprved plan

11 Medical Prvider Infrmatin t include the fllwing: Identify service area Emergency care t be available at participating hspitals. 24 hur initial r referral f nn-emergency care. List all prviders alphabetically by specialty and lcatin, t be updated at least quarterly. Include phne numbers. Prvide cpy f written prvider agreement describing the relatinship with the plan. Cpies f all executed cntracts t be made available t the Chairman n request. Prvide a descriptin f the selectin and remval criteria fr plan prviders. (Cnfidential) Netwrk shall include at least ne ccupatinal health clinic, auxiliary, ccupatinal health clinic r hspital with a bard eligible/certified ccupatinal health physician. Specialties: Minimum f three prviders in three unrelated grups, r five prviders in tw unrelated grups. Cardilgy Chirpractic Medicine Dentistry Dermatlgy Family Practice Gastrenterlgy General Hspital General Surgery Internal Medicine Neurlgy Neursurgery Ob-Gyn Ophthalmlgy Optmetry Orthpedic Surgery Otlarynglgy Physical Medicine & Rehabilitatin Physical Therapy Plastic Surgery Pdiatry Psychiatry Psychlgy Pulmnary Medicine Radilgy Thracic Surgery Urlgy Other

12 Plans may chse nt t cver all specialties. Hwever, the plan must indicate that nn-cvered services are available withut penalty frm any prvider n the Wrkers Cmpensatin List f Apprved Prviders and services are nt subject t the plan s fees, review r appeal prcedures. Utilizatin Review & Appeal Prcedures & Standards: Prvide a descriptin f the plan s established written clinical criteria fr Utilizatin Review. Prvide a descriptin f Utilizatin Review prcedures. Utilizatin Review is t be cnducted by licensed review prfessinals. Physicians must be licensed in the State f Cnnecticut. Nurses and thers must hld current and valid licenses frm any state. Attach names, psitins, and states f licensure f all individuals cnducting Utilizatin Review. In rder t assure that the cmpany which cnducts utilizatin review within yur wrkers cmpensatin medical care plan meets the requirements set frth by administrative regulatin , cmplete the attached standards fr cmpliance dcument [see fllwing pages]. Please nte that the certificatin must be executed by smene in authrity at the entity which is applying fr the certificate t cnduct the medical care plan. Tll-free access minimum 40 hurs per week during regular business hurs. Prvisin fr prtecting the cnfidentiality f individual s medical recrds. Plan hspitals t allw n-site review. Prviders t give all relevant infrmatin fr review. Failure is grunds fr denial. Financial incentives fr denials prhibited. Initial Review: May be requested by an emplyee, emplyer, prvider, the plan r its UR cntractr. The plan must respnd t a review request within tw business days f the request.

13 Appeal: The plan must allw a minimum f 15 days t appeal the initial nncertificatin t the plan s Medical directr. Medical Directr: Shall assign the case t a Physician Reviewer in the same r similar specialty as the cnditin. The Physician Reviewer shall reprt back t the Medical Directr within 15 days f the request r receipt f additinal infrmatin. The Medical Directr shall then issue his/her decisin within 15 days. The plan shall allw a minimum f 15 days t appeal the decisin f the Medical Directr t the plan s Chief Executive Officer. A hearing befre the CEO may be requested in writing. Written and ral evidence may be presented. The hearing shall be held within 15 days f the request. Chief Executive Officer: May use the assistance f an advisry cmmittee. The CEO shall issue his/her decisin within 30 days f the hearing cnclusin r appeal request. The decisin f the CEO shall be final, and appealable t a Wrkers Cmpensatin Cmmissiner nly n grunds f unreasnable, arbitrary r capricius. Expedited Appeals: 24 hurs shall be allwed fllwing an emergency admissin, service, prcedure t request certificatin and cntinuatin f treatment. A denial may be appealed t the Medical Directr wh shall issue a final decisin within 2 days f the request. Reprting f Appeals: The plan shall reprt quarterly t the Chairman n the number and the result f appeals under the plan.

14 CONNECTICUT WORKERS COMPENSATION COMMISSION Utilizatin Review Cmpany minimum standards fr cmpliance with C.G.S and Administrative Regulatins Medical Care Plan: Address: Telephne: Tll Free: Business Hurs (eastern time): Cntact Persn: Direct Telephne #: address: Utilizatin Review Cmpany: Address:

15 1. Please indicate cmpliance with the fllwing standards pursuant t Cnnecticut General Statutes and administrative regulatins : Nt mre than tw (2) business days after receipt f all infrmatin regarding request fr authrizatin f treatment, written ntice shall be prvided t the prvider and emplyee f its determinatin regarding the recmmended treatment. In the case f an emergency cnditin, an emplyee r his representative shall be prvided a minimum f twenty-fur (24) hurs fllwing an admissin, service r prcedure t request certificatin and cntinuing treatment fr that emergency cnditin befre a utilizatin determinatin is made. If a determinatin is made nt t prvide such cntinuing treatment and the emplyee r his representative, the prvider, r the emplyer requests a review f such determinatin, an expedited review shall be cnducted by the medical directr and a final decisin rendered within tw (2) days f the request fr review. Any written ntice f a determinatin nt t certify an admissin, service, prcedure r extensin f stay shall include the reasns and the name and telephne number f the persn t cntact with regard t an appeal. The prvider and the emplyee shall als be prvided with a cpy f the written review and appeal prcedures. The prvider r the emplyee may, within fifteen (15) days f the written ntice f determinatin, ntify the plan f his r her intent t appeal a determinatin t deny payment fr the recmmended treatment. Upn such appeal, at the request f the emplyee r prvider, a practitiner in a specialty relating t the emplyee's cnditin fr the purpse f reviewing the initial decisin shall be prvided Within fifteen (15) days f the request fr such review and submissin f any further dcumentatin regarding the review, the reviewing practitiner shall submit his pinin regarding such recmmended treatment t the medical directr f the medical care plan wh shall, within fifteen (15) days thereafter, render a written decisin regarding such treatment. The emplyee, the prvider r the emplyer may request a further review f the medical directr's written decisin; such request fr further review shall be in writing and shall be submitted t the chief executive fficer f the medical care plan within fifteen (15) days f the medical directr's written decisin. The party requesting further review shall have an pprtunity fr a hearing if such party requests it in writing and may, at such party's expense, prduce whatever written supprt r ral testimny it wishes at any such hearing. Such hearing shall be cnducted within fifteen (15) days f the written request. The chief executive fficer f the medical care plan shall make any final determinatin f such request fr further review and may utilize an advisry cmmittee t assist him in his determinatin. The chief executive fficer shall issue a final written decisin n the request fr further review as sn as practical but, in any event, within thirty (30) days f the later f the date f submissin f the written request fr such review r the date f cnclusin f the hearing requested as part f such review. The utilizatin review and appeal prcedures persnnel shall, at a minimum, satisfy the fllwing standards: Nurses and ther health prfessinals ther than physicians making utilizatin review recmmendatins and decisins shall hld current and valid licenses frm a state licensing agency in the United States. Physicians making utilizatin review recmmendatins and decisins shall hld current and valid licenses in the State f Cnnecticut.

16 Utilizatin review staff shall be generally available by tll-free telephne, at least frty hurs per week during regular business hurs. Each utilizatin review prfessinal shall cmply with all applicable state and federal laws t prtect the cnfidentiality f individual medical recrds; summary and aggregate data shall nt be cnsidered cnfidential if it des nt prvide sufficient infrmatin t allw identificatin f individual patients. Each utilizatin review prfessinal shall cnduct its telephne and n-site infrmatin gathering reviews and hspital cmmunicatins during the hspitals reasnable and nrmal business hurs, unless therwise mutually agreed. Utilizatin review prfessinals shall identify themselves by name and by the name f their rganizatin, if any, and, fr n-site reviews, shall carry picture identificatin. N utilizatin review prfessinal may receive any financial incentive based n the number f denials f certificatin made by such prfessinal. 2. Indicate hw the UR cmpany is reimbursed fr services: 3. Describe the prfessinal liability cverage maintained by the UR cmpany with respect t legal liability: 4. Indicate hw reviewers are cmpensated:

17 5. Is the UR cmpany currently accredited by URAC? 6. List all states where the cmpany is currently licensed t perfrm UR: 7. Have any sanctins, fines, revcatin, r restrictin f licensure been impsed n the UR cmpany by any regulatry agency? If yes, please explain:

18 CERTIFICATION STATEMENT The undersigned, being duly swrn, hereby certifies n behalf f (cmpany) that the infrmatin prvided herein is true and accurate, and further swears that by virtue f my psitin as, I am vested with the (fficer) authrity t attest t these matters as well as t legally bind (cmpany) fr any liability/actin n accunt f any untruths, misrepresentatins r inaccuracies cntained herein. Subscribed and swrn t befre me Signature f Executive Officer r Individual f Similar Rank this day f, 20 Ntary Ntary Public/Cmmissiner f the Superir Curt Print Name f Signatry Title My Cmmissin expires, 20

19 Implementatin f Safety & Health Cnnecticut Administrative Regulatins 31-40v-1 thrugh 31-40v-11 Safety Prgram Officers (SPOs) frm the Wrkers Cmpensatin Cmmissin are visiting Cnnecticut emplyers t assist them in cmplying with the State s recently effective safety and health cmmittee regulatins, pursuant t C.G.S. Sectin 31-40v-1. Fllwing the initial visit, a Safety Prgram Officer will return within 30 days t verify the emplyer s cmpliance with the regulatins. At that time, the Safety Prgram Officer will review existing safety and health cmmittees and/r prgrams. As directed by the Chairman, SPO s will perfrm a walk thrugh f the emplyer s facility. T ensure that emplyers are prepared fr these meetings, please have the fllwing infrmatin available: Cmpleted inspectin frm (included in this infrmatin packet) A cpy f safety cmmittee meeting minutes frm ne cmmittee meeting A cpy f the psted rster cntaining cmmittee member names and departments T answer any f yur questins r address any cncerns yu may have, the staff f the Cmmissin s Safety and Health Services can be cntacted at the Office f the Chairman, in Hartfrd, at (860)

20 INSPECTION FORM DATE: COMPANY NAME: COMPANY ADDRESS: COMPANY CONTACT: TELEPHONE # BUSINESS TYPE: PPO: YES NO TOTAL EMPLOYEES: COMPANY SAFETY COMMITTEE: YES NO TOTAL SAFETY COMMITTEE MEMBERS TOTAL EMPLOYER MEMBERS TOTAL EMPLOYEE MEMBERS SAFETY COMMITTEE CHAIRPERSON DATE SELECTED DATE OF LAST SAFETY MEETING DOES THE COMPANY HAVE A MASTER LIST OF SAFETY COMMITTEE MEMBERS? YES NO IF YES, DOES THIS MASTER LIST CONSIST OF MEMBER NAMES AND THEIR DEPARTMENTS? YES NO IS THIS LIST POSTED WHERE ALL EMPLOYEES HAVE ACCESS? YES NO ARE SAFETY MEETING MINUTES KEPT? YES NO IF YES, DO THESE MEETING MINUTES LIST THE ATTENDEES? YES NO ARE ALL MEMBERS OF THE SAFETY COMMITTEE PAID FOR ALL TIME SPENT ON COMMITTEE ACTIVITIES? YES NO

21 DO SAFETY COMMITTEE MEETINGS INCLUDE: ACCIDENT INVESTIGATIONS YES NO SAFETY INSPECTIONS YES NO SAFETY TRAINING PROGRAMS YES NO HAZARD IDENTIFICATION AND/OR WORKPLACE EXPOSURE PROGRAMS YES NO FOLLOW-UP PROCEDURES FOR OPEN SAFETY ITEMS YES NO A WRITTEN AGENDA YES NO A RECORD OF ALL SUGGESTIONS AND RECOMMENDATIONS YES NO FREQUENCY OF SAFETY MEETINGS DURATION OF SAFETY MEETINGS ARE RESPONSIBILITIES ASSIGNED TO CORRECT SAFETY ISSUES? YES NO HAVE ALL SAFETY COMMITTEE MEMBERS BEEN TRAINED IN THEIR RIGHTS AND RESPONSIBILITIES AS COMMITTEE MEMBERS? YES NO IF YES, HOW?

22 State f Cnnecticut Wrkers Cmpensatin Cmmissin Wrkers Cmpensatin Medical Care Plan Emplyer Participatin Frm Plan Spnsr Name f Emplyer Subsidiary r D/B/A (circle ne) Business Lcatin(s) Nature f Business Ttal Number f Emplyees If mre than ne business lcatin, attach addresses and number f emplyees at each site. Name and Title f Emplyer Representative Phne ( ) - Signature f Emplyer Representative Current Wrkers Cmpensatin Carrier (please indicate if authrized self-insurer) Plicy N. Plicy Term Claims Office Lcatin

23 Plan Participatin 1. Are any f yur emplyees cvered by a cllective bargaining agreement? Yes N If YES, include a statement that the Emplyer s participatin is nt in vilatin f any cllective bargaining agreement, a cpy f which will be made available t the Chairman upn request. 2. Has the Emplyer agreed t the perfrmance f all bligatins as utlined in the riginal Plan Applicatin? Yes N If NO, please attach a detailed descriptin f any Emplyer respnsibilities which have been amended by a client-spnsr cntract. 3. Attach a cpy f Apprved Health & Safety Cmmittee Certificate (emplyers f 25 r mre). 4. Attach a descriptin f the financial arrangements between Plan and Emplyer (CONFIDENTIAL). 5. Attach a cpy f the plain language explanatin t be distributed t emplyees. 6. Attach a descriptin f the Mdified/Light Duty Wrk Prgram (emplyers f 50 r mre).