Section 127.652. Contents of an application to be authorized as a URO or PRO

(a) An application to be authorized as a URO or PRO shall include the following:

(1) Ownership information, including the following:

(i) A disclosure of whether the applicant is owned or controlled, directly or indirectly, by a self-insured employer, a third-party administrator, a workers’ compensation insurer or a provider.

(ii) A list of the owners of the proposed URO or PRO with a 5% or greater ownership interest; and a disclosure of whether any such owner is a director or officer of a self-insured employer, a third-party administrator, a workers’ compensation carrier or is a provider.

(iii) A chart of the relationship between the proposed URO or PRO, its parent and other subsidiaries of the parent corporation, if the proposed URO or PRO is a subsidiary or affiliate of another corporation.

(iv) A list of directors and officers of the proposed URO or PRO; and a disclosure of whether any such director or officer is a director or officer of a self-insured employer, a third-party administrator, a workers’ compensation carrier or is a provider.

(2) An organization chart listing reporting relationships and the positions supporting the operations of the URO or PRO, particularly in the areas of UR, quality assurance and case communication systems. An addendum to the chart shall describe how increased utilization of the URO or PRO services will affect staffing.

(3) A complete list of participating providers performing reviews for the URO or PRO:

(i) Identifying whether the provider is an employe or affiliate of or has entered into a contract or agreement with the URO or PRO.

(ii) Identifying the geographic area where the provider practices the provider’s speciality.

(iii) Explaining how the contractual arrangements with providers ensure that the URO or PRO will be able to meet the requirements of the act and of this subchapter for UROs and PROs.

(iv) Establishing that it employs, is affiliated with, or has contracts with a sufficient number and specialty distribution of providers to perform reviews as required by the act and this subchapter.

(v) Including curriculum vitae of each reviewer.

(4) A copy of generic form contracts or letters of agreement used by the applicant to contract with participating providers.

(5) A description of the applicant’s case communication system.

(6) A description of the applicant’s utilization or peer review system which demonstrates how the applicant meets the standards of this subchapter.

(7) A description of the applicant’s quality assurance system.

(8) A description of the applicant’s fee structure.

(b) Subsequent to filing its application, the URO or PRO shall advise the Bureau of any changes to the information provided under subsection (a).

(c) The obligation of a URO or PRO to advise the Bureau of any changes to the criteria in subsection (a) shall continue subsequent to approval of its application for authorization by the Bureau.

Notation

Cross References

This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).