Section 531.1 - Provision of required medical services by coordinated care organization(1) Medical services required by the act may be provided through a coordinated care organization which is certified by the secretary subject to the following:(i) Each application for certification shall be accompanied by a reasonable fee prescribed by the department. A certificate is valid for such period as the department may prescribe unless sooner revoked or suspended.(ii) Application for certification shall be made in such form and manner as the department shall require and shall set forth information regarding the proposed plan for providing services.(iii) Where the secretary certifies that the coordinated care organization within which all of the designated physicians or other health care providers referred to in clause (f.1)(1)(i) are members, the secretary shall ensure that all the requirements of this clause are met.(2) 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.(3) The secretary shall certify an entity as a coordinated care organization if the secretary finds that the entity:(i) Possesses the capacity to provide all primary medical services as designated by the secretary in a manner that is timely and effective.(ii) Maintains a referral capacity to treat other injuries and illnesses not covered by primary services but which are covered by this act.(iii) Provides a case management and evaluation system which includes continuous monitoring of treatment from onset of injury or illness until final resolution.(iv) Provides a case communication system which relates necessary and appropriate information among the employe, employer, health care providers and insurer.(v) Provides appropriate peer and utilization review and a care dispute resolution system.(vi) Meets quality of care and cost-effectiveness standards based upon accepted standards in the profession, including health care effectiveness measures of the Pennsylvania Health Care Cost Containment Council and recommendations on quality of care by the Workers' Compensation Advisory Council.(vii) Complies with any other requirements of law regarding delivery of health care services.(viii) Establishes a written grievance procedure for prompt and effective resolution of patient grievances.(4) The secretary shall refuse to certify or may revoke or suspend certification of any coordinated care organization if the secretary finds that:(i) the plan for providing health care services fails to meet the requirements of this section;(ii) service under the plan is not being provided in accordance with terms of the plan as certified; or(iii) services under the plan do not meet accepted professional standards for quality, cost-effective health care.(5) A person participating in utilization review, quality assurance or peer review activities pursuant to this section shall not be examined as to any communication made in the course of such activities or the findings thereof, nor shall any person be subject to an action for civil damages for actions taken or statements made in good faith.(6) Health care providers designated as rural by HCFA or located in a county with a rural Health Professional Shortage Area who are attempting to form or operate a coordinated care organization may be excluded from meeting some or all of the minimum requirements set forth in paragraphs (2) and (3), as shall be determined in rules or regulations promulgated by the department.(7) The department shall have the power and authority to promulgate, adopt, publish and use regulations for the implementation of this section.1915, June 2, P.L. 736, No. 338, § 306(f.2), added 1993, July 2, P.L. 190, No. 44, § 8, effective in 60 days. Amended 1996, June 24, P.L. 350, No. 57, § 4, effective in 60 days.