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SelectNet provider manual

Pinnacol Assurance SelectNet Provider Manual.
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SelectNet Provider Manual Updated


The SelectNet® Provider Manual is periodically updated to reflect changes in SelectNet’s processes and policies. Updates may also be made to reflect changes in the Colorado Division of Workers’ Compensation (DOWC) Rules of Procedure. The following changes have been made to the SelectNet Provider Manual, effective immediately.

Throughout the manual

  • Links were added throughout the document to the DOWC’s homepage, the DOWC’s Rules of Procedure, Pinnacol’s webpage, Pinnacol’s Workers’ Compensation Basics for Provider’s course, SelectNet directory and Pinnacol’s provider portal.
  • The term “Pinnacol Online” was changed to “Pinnacol’s provider portal.”
  • Standardization of the term “SelectNet Agreement” referring to the participant’s contract with Pinnacol. 
  • Standardization of the terms “DOWC Rule 16,” “DOWC Rule 17,” and “DOWC Rule 18” referring to specific DOWC Rules of Procedure.
  • Standardization of the term “Provider Network Management department” referring to the team that manages the SelectNet network.
  • Standardization of the terms “CMS1500” and “UB04” referring to billing forms.
  • The term “PCP” was updated to “occupational health primary care physician (PCP).” 

Section 1 - Pinnacol Assurance and SelectNet

  • Pinnacol’s former mission has been replace with Pinnacol’s current vision. (p. 1)

Section 2 - Regulatory Requirements

  • NEW: The explanation of the difference between “in the course of” and “arising out of” was added (p. 1)
  • NEW: IME reports should be served concurrently to all parties no later than 20 days after the exam per DOWC Rule 18. (p. 3)
  • The list of provider types eligible for Level I Accreditation was updated per the DOWC’s website. (p. 3)
  • Pinnacol’s Workers’ Compensation Basics course was removed as a credentialing requirement (the course is encouraged, but no longer required). (p. 3) 
  • The term “Pinnacol’s Level I” course was renamed “Pinnacol’s Workers’ Compensation Basics for Providers course.” (p. 3)

Section 3 - Provider Responsibilities and Case Management

  • NEW: Information about Pinnacol’s return to work (RTW) consultants was added. (p. 5)
  • NEW: Communication expectations when a claim is represented. (p. 6)
  • Clarified that demand appointments are also referred to as payer-made appointments. (p. 7)
  • Clarified demand appointments should be scheduled with a physician. (p. 7)
  • How to locate the SelectNet directory through pinnacol.com was added. (p. 8)
  • NEW: Prior authorization requirements for prescriptions was added per DOWC Rule 18. (p. 8)
  • Clarified when a physician's signature is needed in medical records when treatment is rendered by a mid-level practitioner. (p. 9)
  • Replaced claim “closure” with the term “resolution.” (p. 10)
  • NEW: If the PCP is not Level II accredited, the PCP should refer an injured worker to a Level II accredited physician to complete an IR within 20 days of MMI per DOWC Rule 5. (p. 11)

Section 4 - Utilization Management

  • Prior authorization requirements were updated per DOWC Rule 16. (p. 1)
  • Information required in a prior authorization request was updated per DOWC Rule 16. (p. 1)
  • Responses to prior authorization requests was updated to 10 days per DOWC Rule 16. (p. 2)
  • NEW: Pinnacol can issue retroactive denials to services rendered without prior authorization. (p. 2)

Section 5 - Provider Responsibilities and Quality Management

  • Credentialing forms are available on Pinnacol’s provider portal. (p. 1)
  • NEW: The contractual expectation that SelectNet participations and staff meet with their provider relations specialist (PRS) when requested or at the discretion of Pinnacol’s Senior Medical Director. (p. 3)
  • NEW: Providers should make themselves available to receive performance feedback from Pinnacol. (p. 3)
  • Billing requirements for providers was updated to include: 
  • Providers must bill their own name, credentials, and NPI. (p. 3)
  • Providers are not permitted to bill under a supervising physician or other providers’ credentials. (p. 3) 
  • A pattern of improper billing may be reported to regulatory authorities and result in termination from SelectNet. (p. 3)
  • Submitted bills can be viewed in Pinnacol’s provider portal. (p. 4)
  • Links to the websites for two of the clearinghouses Pinnacol utilizes were updated. (p. 4)
  • The medical bill fax number. (p. 5)
  • NEW: The term “explanation of remittance (EOR).” (p. 6)

Section 6 - Pinnacol’s Responsibilities

  • How to locate the SelectNet directory through pinnacol.com was added. (p. 1)
  • NEW: Providers and staff must keep a current email address on file with PNM to receive Provider Update emails. (p. 2)
  • How SelectNet PCPs can receive clinic profiling reports through Pinnacol’s provider portal was updated. (p. 3)
  • The provider feedback loop (FBL) count process for clinics and ancillary service vendors was updated. (p. 4)

Section 7 - Appendices

Appendix A

PCP Participation Standards

  • NEW: The PCP is expected to render longitudinal care to any injured worker the PCP begins to treat as the injured worker’s DP and only in rare circumstances should the injured worker be transferred to another clinic for ongoing care. (p. 1)
  • Clarified a written job offer or job description may also be referred to as a Rule 6, modified duty, or task letter. (p. 1)
  • Clarified what documentation is required when an injured worker has reached MMI. (p. 2)
  • Provided specific examples of “other written correspondence.” (p. 2)
  • NEW: The definition of what is considered rural or frontier based was added per DOWC Rule 16. (p. 3)
  • NEW: PCPs should make a referral to a SelectNet specialist within 2 business days from the date the need for specialist treatment is identified. (p. 3)

Urgent Care Participation Standards

  • NEW: Urgent care providers should not refer injured workers to a specialist unless it is a genuine emergency. All non-emergent specialty referrals should be made by the designated provider (DP). (p. 3)
  • Accredited and certified information was updated per DOWC Rule 18. (p. 3)

Specialist Participation Standards

  • Provided specific examples of “other written correspondence.” (p. 6)

Rehab Service Provider Participation Standards

  • NEW: Progress reports should be provided to the referring provider within 5 days of service. (p. 7)

Interpretation Vendor Participation Standards

  • Newly established standards for contracted interpreters. (pp. 8-9)

Appendix D

  • Failure to perform one or more obligations outlined in DOWC Rules 16 or 18 was added as a quality of service issue. (p. 21)
  • The FBL count process for clinics and ancillary service vendors was updated. (pp. 21-22)

Section 8 - Glossary

  • New section added. (pp. 1-3)

The SelectNet Provider Manual is a resource for providers and clinic staff who need to access information about working with Pinnacol and following the requirements of the Workers’ Compensation Act of Colorado.Itdefines key responsibilities and requirements for clinics and providers participating in SelectNet and Pinnacol’s responsibilities in working with SelectNet providers. This manual was developed by Pinnacol Assurance and is intended solely for the use of Pinnacol Assurance and Pinnacol Assurance's preferred provider network, SelectNet.

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