PENNSYLVANIA
Employee selects from Panel
Employers have the option to establish a list of designated health care providers under section 306(f.1)(1)(i) of the act (77 P. S. § 531(1)(i)). (b) If an employer has established a list of providers which meets the requirements of the act and this subchapter, an employee with a work-related injury or illness shall seek treatment with one of the designated providers from the list. The employee shall continue to treat with the same provider or another designated provider for 90 days from the date of the first visit for the treatment of the work injury or illness. (c) The employer may not require treatment with any one specific provider on the list, nor may the employer restrict the employee from switching from one designated provider to another designated provider. (f) If an employer chooses not to establish a list of designated providers, the employee shall have the right to seek medical treatment from any provider from the time of the initial visit. (34 Pa. Code § 127.751)
Change of Provider
The employee has the right, during this 90-day period, to switch from one health care provider on the list to another provider on the list, and that all the treatment shall be paid for by the employer. (34 Pa. Code § 127.755(b)(3))
The employee has the right to seek treatment from any health care provider after the 90-day period has ended, and that treatment shall be paid for by the employer, if it is reasonable and necessary. (34 Pa. Code § 127.755(b)(7))
Panels
Allowed*
Panel Provisions
If an employer establishes a list of designated health care providers, there shall be at least 6 providers on the list.
(1) At least 3 of the providers on the list shall be physicians.
(2) No more than 4 of the providers on the list may be CCOs.
(b) The employer shall include the names, addresses, telephone numbers and areas of medical specialties of the designated providers on the list.
(c) The employer shall include on the list only providers who are geographically accessible and whose specialties are appropriate based on the anticipated work-related medical problems of the employees.
(d) If the employer lists a CCO, as an option on the list of designated providers, the employer may not individually list any provider participating in that CCO, under circumstances when those individually listed providers are bound by the terms of the CCO for the treatment rendered to the injured workers.
(e) The employer may change the designated providers on a list. However, changes to the list may not affect the options available to an employee who has already commenced the 90-day treatment period. (34 Pa. Code § 127.752)
The employer may not include on the list of designated health care providers a physician or other health care provider who is employed, owned or controlled by the employer or the employer's insurer, unless employment, ownership or control is disclosed on the list. (b) For purposes of this section, "employer's insurer" means the insurer who is responsible for paying workers' compensation under the terms of the act. (34 Pa. Code § 127.753)
If an employer chooses to establish a list of providers, the list shall be posted in prominent and readily accessible places at the worksite. These places include places used for treatment and first aid of injured employees and employee informational bulletin boards. (34 Pa. Code § 127.754)
If an employer's list of designated providers fails to comport with the act and this subchapter, the employee shall have the right to treat with a health care provider of the employee's choice from the time of the initial visit. (34 Pa. Code § 127.751(e))
PENNSYLVANIA CCO
Employee Selects from Panel
Employers have the option to establish a list of designated health care providers under section 306(f.1)(1)(i) of the act (77 P. S. § 531(1)(i)). (b) If an employer has established a list of providers which meets the requirements of the act and this subchapter, an employee with a work-related injury or illness shall seek treatment with one of the designated providers from the list. The employee shall continue to treat with the same provider or another designated provider for 90 days from the date of the first visit for the treatment of the work injury or illness. (c) The employer may not require treatment with any one specific provider on the list, nor may the employer restrict the employee from switching from one designated provider to another designated provider. (f) If an employer chooses not to establish a list of designated providers, the employee shall have the right to seek medical treatment from any provider from the time of the initial visit. (34 Pa. Code § 127.751)
The coordinated care organization shall include an adequate number and specialty distribution of licensed health care providers in order to assure appropriate and timely delivery of services required under the act and an appropriate flexibility to workers in selecting providers. Services may be provided directly, through affiliates or through contractual referral arrangements with other health care providers. (77 P.S. § 531.1(2))
Change of Provider
The employee has the right, during this 90-day period, to switch from one health care provider on the list to another provider on the list, and that all the treatment shall be paid for by the employer. (34 Pa. Code § 127.755(b)(3))
The employee has the right to seek treatment from any health care provider after the 90-day period has ended, and that treatment shall be paid for by the employer, if it is reasonable and necessary. (34 Pa. Code § 127.755(b)(7))
Panels
Allowed*
Panel Provisions
If an employer establishes a list of designated health care providers, there shall be at least 6 providers on the list..
(1) At least 3 of the providers on the list shall be physicians.
(2) No more than 4 of the providers on the list may be CCOs.
(b) The employer shall include the names, addresses, telephone numbers and areas of medical specialties of the designated providers on the list.
(c) The employer shall include on the list only providers who are geographically accessible and whose specialties are appropriate based on the anticipated work-related medical problems of the employees.
(d) If the employer lists a CCO, as an option on the list of designated providers, the employer may not individually list any provider participating in that CCO, under circumstances when those individually listed providers are bound by the terms of the CCO for the treatment rendered to the injured workers.
(e) The employer may change the designated providers on a list. However, changes to the list may not affect the options available to an employee who has already commenced the 90-day treatment period. (34 Pa. Code § 127.752)
The employer may not include on the list of designated health care providers a physician or other health care provider who is employed, owned or controlled by the employer or the employer's insurer, unless employment, ownership or control is disclosed on the list. (b) For purposes of this section, "employer's insurer" means the insurer who is responsible for paying workers' compensation under the terms of the act. (34 Pa. Code § 127.753)
If an employer chooses to establish a list of providers, the list shall be posted in prominent and readily accessible places at the worksite. These places include places used for treatment and first aid of injured employees and employee informational bulletin boards. (34 Pa. Code § 127.754)
If an employer's list of designated providers fails to comport with the act and this subchapter, the employee shall have the right to treat with a health care provider of the employee's choice from the time of the initial visit. (34 Pa. Code § 127.751(e))
The information on this website constitutes summary information only and does not constitute legal advice. Review of the full text of the referenced statutes and regulations may be necessary. Coventry Health Care Workers' Compensation, Inc. makes no representations or warranties about the accuracy of the information contained on this website.