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PROVIDER CERTIFICATION
INTRODUCTION
Rules and Regulations for Certification of Health Care Providers
In accordance with the provisions of 19 Del.C.
§2322(D), certification is required for a health care provider to provide
treatment to an employee, pursuant to Delaware's Workers' Compensation Statute,
without the requirement that the health care provider first pre-authorize each
health care procedure, office visit or health care service to be provided to
the employee with the employer if self-insured, or the employer's insurance
carrier. Pursuant to 19 Del.C. §2322B and F, for purposes of the
Certification requirements of §2322D, "health care provider" specifically
includes physicians, chiropractors and physical therapists providing treatment
to an injured worker during his/her period of inpatient or outpatient
hospitalization; all other personnel employed by a hospital providing treatment
to an injured worker during his/her period of inpatient or outpatient
hospitalization are excluded from the Certification requirements of this
Subsection. With regard to any hospital facility providing inpatient and/or
outpatient services, to be Certified in accordance with the provisions of
§2322D so that pre-authorization from the employer or insurance carrier for the
employer is not required for each health care procedure, office visit or health
care service provided to an injured employee, the person completing and signing
the Health Care Provider Application for Certification on behalf of the
hospital shall have the authority to do so and must attest to and be
responsible for the completion of all of the requirements set forth on such
Application. Services provided by an emergency department of a hospital
pursuant to §2322B(h)(3) shall not be subject to the requirement of
Certification. The provisions of §2322(D) shall apply to all treatments to
employees provided after the effective date of the rule/regulation provided by
this subsection and regardless of the date of injury. A health care provider
shall be certified only upon meeting the following minimum certification
requirements:
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Have a current license to practice, as applicable;
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Meet other general certification requirements for the specific provider type;
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Possess a current and valid Drug Enforcement Agency ("DEA") registration,
unless not required by the provider's discipline and scope of practice;
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Have no previous involuntary termination from participation in Medicare,
Medicaid or the Delaware workers' compensation system. Any such involuntary
termination shall be considered to be inconsistent with certification;
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Have no felony convictions in any jurisdiction, under a federal-controlled
substance act or for an act involving dishonesty, fraud or misrepresentation. A
felony conviction in any jurisdiction under a federal-controlled substance act
or for an act involving dishonesty, fraud or misrepresentation shall be
considered to be inconsistent with certification;
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Provide proof of adequate, current professional malpractice and liability
insurance.
In addition to the above, the health care
provider to be certified must agree to the terms and conditions set forth on
the Health Care Provider Application for Certification, as follows:
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Comply with Delaware workers' compensation laws and rules;
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Maintain acceptable malpractice coverage;
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Complete state-approved continuing education courses in workers' compensation
every two (2) years from the date of the health care provider's initial
certification. A listing of continuing education courses in workers'
compensation care approved by the State of Delaware, Department of Labor,
Office of Workers' Compensation, will be posted on the Office of Workers'
Compensation website. To maintain certification, every two (2) years from the
initial date of certification the health care provider must provide written
notification to the Office of Workers' Compensation of compliance with the
continuing education course requirement noted above, setting forth the name of
the course(s) completed and the date of completion;
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Practice in a best-practices environment, complying with practice guidelines
and Utilization Review Accreditation Council ("URAC") utilization review
determinations;
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Agree to bill only for services and items performed or provided, and medically
necessary, cost-effective and related to the claim or allowed condition;
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Agree to inform an employee of his or her liability for payment of non-covered
services prior to delivery;
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Accept reimbursement for and not unbundle charges into separate procedure codes
when a single procedure code is more appropriate;
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Agree not to balance bill any employee or employer. Employees shall not be
required to contribute a co-payment or meet any deductibles;
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Agree to have knowledge of all statements authorized under the certified health
care provider's signature and to be responsible for the content of all bills
submitted pursuant to the provisions of 19 Del.C.
§§2322B, C, E, F;
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Agree to provide written notification to the Department of Labor, Office of
Workers' Compensation, State of Delaware, of any relevant changes to the
requirements set forth in the Certification Form within thirty (30) days of the
health care provider's knowledge or receipt of notice of any and all such
change(s).
Notwithstanding the provisions of §2322(D), any
health care provider may provide services during one office visit, or other
single instance of treatment, without first having obtained prior authorization
from the employer if self-insured, or the employer's insurance carrier, and
receive reimbursement for reasonable and necessary services directly related to
the employee's injury or condition at the health care provider's usual and
customary fee, or the maximum allowable fee pursuant to the workers'
compensation health care payment system adopted pursuant to 19 Del.C. §2322(B),
whichever is less. The provisions of this subsection, §2322(D), are limited to
the occasion of the employee's first contact with any health care provider for
treatment of the injury, and further limited to instances when the -2- health
care provider believes in good faith, after inquiry, that the injury or
occupational disease was suffered in the course of the employee's employment.
The provisions of this subsection, §2322(D), shall apply to all treatments to
injured employees provided after the effective date of this subsection, and
regardless of the date of injury.
The health care provider's completed Certification Form is to be mailed to:
Mr. John F. Kirk, III
State of Delaware
Department of Labor
Office of Workers' Compensation
P.O. Box 9954
Wilmington, DE 19809-9954
Instructions and provisions for completing the Certification Form online will
be published on the Office of Workers' Compensation website when available.
Download
Provider Certification Instructions and Form
Workers’ Compensation Certified Health Care Providers
The Health Care Advisory Panel in accordance with 19 Del. C. § 2322D, established a certification process for health care providers who treat Delaware’s injured workers. This link provides a list of those health care providers who are certified to date. Each day the Office of Workers’ Compensation receives additional applications and updated information; consequently, the list cannot be all inclusive and will regularly change to reflect newly certified providers. If you do not see a particular health care provider on this list and you need to know if that provider is certified to treat workers’ compensation patients, we recommend you check directly with the provider.
The Certified Provider List can be downloaded in
excel
or pdf format.
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