A certified PPO is a plan certified by the Department of Health, owned, operated or administered by an entity that has the capacity to establish a network of service providers that provides or arranges for the coordination and delivery of all required services.
Benefits of a certified PPO model include:
- Direction of Care for 30 days from the first visit with a PPO provider
- Discounted fee arrangements with PPO participating providers
- Mandatory care management including Utilization Review, Return-to-Work, and Telephonic and Field Case Management
Recommendation of Care
A Recommendation of Care model is defined as actively endorsing or promoting the use of a designated network or health care provider(s) for the treatment of an injured employee.
Benefits of a Recommendation of Care model include:
- Initial treatment required with a PPO provider (except for emergencies)
- Carrier/employer may recommend the network to all injured workers
- PPO discounts available on all claims where ROC rules have been followed
- ROC program may be used in non-certified counties
- Existence of carrier/network contract is considered recommendation of care even if not actively recommending