§2051.285. Workers' Compensation Preferred Provider Program Payor Agreements

Any payor agreements between WC PPP administrators and payors shall contain, at a minimum:

 

a)         Terms requiring and specifying all incentives to be provided to the insured to utilize services of a provider that has entered into an agreement with the administrator;

 

b)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements, the payor shall ensure that the beneficiary so referred shall incur no greater liability than had the beneficiary received services from a preferred provider, except as provided under Section 8.1a(c)(2) and Section 8.2(e) of the Workers' Compensation Act;

 

c)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements consistent with Section 8.1a of the Workers' Compensation Act, the WC PPP shall ensure that the covered employee will be provided the covered services by a non-preferred provider in accordance with the fees established by the Workers' Compensation Fee Schedule (see 50 Ill. Adm. Code 9110.90 and the WCC website at https://iwcc.ingenix.com/ iwcc.asp).

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)