The Intelligent Insurance Solution

Provider Expectations

To be a Trust provider, the provider must agree to:

  1. Provide medically appropriate and customary medical services to injured workers in the most efficient and prompt manner possible.
  2. Practice medicine under the laws and regulations of Connecticut to provide medical treatment, and has attending privileges or affiliation with at least one Connecticut licensed acute care hospital; with the exception of Chiropractic providers.
  3. Ensure that injured workers are seen within five (5) business days upon request for an appointment and only by a physician listed in the Provider Directory.
  4. Assess the injured worker’s ability to perform some type of work, focusing on the injured worker’s ability – not disability. Work capacity documentation should include specific work capabilities such as, but not limited to lifting, pushing, twisting, bending and standing. The Participating Provider agrees to communicate this work capacity in a timely manner to the injured workers, employer and to the Trust.
  5. Not issue disability absences without first examining the injured worker, or post date a disability note to cover previous absences initiated by the injured worker. 
  6. Provide the Trust within one (1) business day of an office visit a Work Status Form. Any questions regarding this form must be addressed within the same business day with the injured worker’s assigned adjuster at the Trust.
  7. Provide within five (5) business days, a complete report of the employee’s status, including the following:
    1. Patient history
    2. History of the current injury or illness
    3. Current medical status
    4. Treatment plan, goals
    5. Follow-up appointments - should be frequent as necessary to facilitate return to work.
  8. Comply with pre-certification requirements. The Trust will notify the Participating Provider, in writing, thirty days in advance of any change in pre-certification requirements.
  9. Comply with the Trust’s pharmacy benefit management (PBM) program by supplying written scripts to injured workers and refraining from dispensing internally within the practice. If prescriptions are dispensed internally through error, the provider will accept payment for such prescriptions at the same reimbursement rate the Trust could have obtained through the PBM vendor.
  10. Obtain written authorization from the Trust prior to supplying injured workers with items considered to be durable medical equipment (DME) costing over $50.00. The Trust has the sole right of selection of vendors for such equipment.
  11. Ensure that referrals to other specialists are made from within the Trust Provider Network and documented clearly in the medical report submitted to the Trust. Providers are encouraged to check the Trust’s website for the most current listing of providers in the network.
  12. Comply with the State of Connecticut Clinical Practice Guidelines and other widely accepted disability duration and treatment guideline.
  13. Allow appropriate Trust personnel full access to the medical records of covered injured workers as necessary for the proper performance of case management and cooperate with case management staff.
  14. Furnish upon request or as required by the Connecticut Workers’ Compensation Act, all information reasonably required by the Trust to document, verify and substantiate covered services and the charges for such services. The provider shall only charge reasonable copying fees for all such information.
  15. Provide the Trust or its designee any information necessary, as requested by the Trust as part of the Trust’s credential process. This information may include requests for copies of licenses, proof of sufficient malpractice insurance coverage, malpractice claim history as well as other information.
  16. Notify the Trust in writing within three (3) business days after the occurrence of:
    1. A change of Participating Providers’ hours of operation, phone and/or fax #s, Tax ID, ownership or business address
    2. Any action taken to restrict, suspend or revoke Participating Provider’s professional license
    3. Any action to restrict, suspend or revoke a Participating Provider’s medical staff privileges
    4. Any action brought against Participating Provider for malpractice and the final disposition of such action by settlement or adjudication
    5. Any termination or cancellation of Participating Provider’s insurance required under this agreement
    6. Any civil or criminal action relating to the provision of medical services
    7. Any other situation which might materially affect Participating Provider’s ability to carry out his/her duties under this agreement or meet any other credentialing criteria
  17. Cooperate with the Trust and its adjusters, case managers and attorneys in providing requested reports, opinion letters and in agreeing to meet with these representatives and, if necessary, agreeing to be deposed or testify at a workers’ compensation hearing. Provider will be paid in accordance with the CT Workers’ Compensation Chairman’s Guidelines for any time needed to perform these additional tasks, including said situations above.
  18. Maintain at all times, professional liability or equivalent self-insurance covering itself, its employees and its agents in amounts consistent with community standards, but at a minimum of $1,000,000 per claim and $3,000,000 aggregate and shall provide evidence of such coverage, if requested. The Participating Provider, its employees and its agents are responsible for their own acts and/or omissions. These provisions will survive termination of this Agreement.
  19. Abide by all of the federal and state confidentiality laws and regulations. This includes the Participating Provider’s obligation to ensure that it meets all of the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). The Trust considers confidential this contract and all matters between the Trust and Participating Provider related to treatment of an injured employee. Participating Provider is not authorized to discuss any injured employee matters with anyone other than representatives of the Trust, representatives of the employers, the employee or the employee’s representative.

Notwithstanding the above, Participating Provider personnel are specifically authorized to communication with and respond to inquiries from any past, present, or future treating providers, diagnostic facilities, pharmacies and any professional providing medical care to the injured employee.