Current through Register Vol. 56, No. 24, December 18, 2024
(a) The WCMCO shall file an annual report
with the Department of Banking and Insurance by April 30th of each year on a
form provided by the Department, which can be found on the Department's
website:
http://www.nj.gov/dobi/division_insurance/managedcare/wcmco.htm,
and which shall include income, expenses, gains or losses, number of new cases
received since the prior report, number of claims submitted since the prior
report, total provider charges, and total sums paid to providers. The annual
report shall be submitted to the following address:
New Jersey Department of Banking and Insurance
Office of Consumer Protection Services
Managed Care
Attn: Workers' Compensation MCO Annual Report
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
(b) The WCMCO shall report all changes in
operations to the Department within 30 days of said change(s), including, but
not limited to, contractual changes, name changes, mergers, acquisitions, sales
of the WCMCO and/or the preferred provider organizations serving as the network
or any changes to the nature of the WCMCO's operations as reflected in its
application and supporting materials filed pursuant to
N.J.A.C. 11:6-2.5 at the address shown in
(a) above.
(c) For purposes of
providing medical services to injured workers under a workers' compensation
insurance policy as set forth in this subchapter, a WCMCO shall meet the
following criteria:
1. The WCMCO shall
arrange for the full range of medical and rehabilitative services necessary to
treat injured workers, including, but not limited to, primary care, orthopedic
care, inpatient care, emergency care, physical therapy and occupational
therapy. In the aggregate, services provided outside of the WCMCO network
should not exceed 20 percent of the WCMCO's cost of medical and rehabilitative
services provided to injured workers.
2. The WCMCO shall provide geographic access
by county to emergency, medical and rehabilitative services for employer sites
covered under its program. Such services may be delivered directly, under
contract, or through written referral protocol;
3. The WCMCO shall have medical care
direction provided and supported by medical directors as defined in this
subchapter;
4. The WCMCO shall
provide medical management, catastrophic case management, disability case
management and monitoring. These case management services must be supported by
documented medical and disability protocol and should be generally accepted by
the medical community;
5. The WCMCO
shall track and manage an injured worker's progress from the onset of injury
through case resolution;
6. The
WCMCO shall contract with participating health care and rehabilitation
providers who are credentialed by the WCMCO according to their documented
criteria, which must specifically include the provider's ability to handle
workplace injuries and illnesses;
7. The WCMCO shall provide written dispute
resolution and grievance procedures to assure that disagreements with medical
providers are resolved without jeopardizing or disrupting patient
management;
8. The WCMCO shall
provide reports as may be required by the Commissioner in areas including, but
not limited to, medical utilization, disability data and costs of the
WCMCO;
9. The WCMCO shall possess
the resources, financial and otherwise, necessary to sustain required
services;
10. The WCMCO shall
establish and implement a fraud detection plan in accordance with the
provisions of
N.J.A.C. 11:6-2.1 1;
11. The WCMCO shall establish and implement
an early return-to-work program in accordance with the provisions of
N.J.A.C. 11:6-2.1 3; and
12. The WCMCO shall establish and implement a
peer and utilization review program and a utilization management program in
accordance with the provisions of
N.J.A.C. 11:6-2.1 4.
