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(7) Nothing in this section precludes a network, entity, administrator, or other third-party, upon agreement with an MPN applicant, from preparing an MPN application on behalf of an insurer or employer.
(8) Describe how the MPN complies with the second and third opinion process set forth in section 9767.7;
(9) Confirm that the application shall set forth that at least 25% of the network physicians are primarily engaged in nonoccupational medicine;
(10) Describe the geographic service area or areas within the State of California to be served and affirm that this access plan complies with the access standards set forth in section 9767.5;
(11) Describe the employee notification process, and attach an English and Spanish sample of the employee notification material described in sections 9767.12(a) and (b);
(12) Attach a copy of the written continuity of care policy as described in Labor Code section 4616.2;
(13) Attach a copy of the written transfer of care policy that complies with section 9767.9 with regard to the transfer of on-going cases from the HCO to the MPN;
(14) Attach a copy of the policy or procedure that is used by the MPN applicant to conduct "economic profiling of MPN providers" pursuant to Labor Code section 4616.1 and affirm that a copy of the policy or procedure has been provided to the MPN providers or attach a statement that the MPN applicant does not conduct economic profiling of MPN providers; and
(15) Describe the number of employees expected to be covered by the MPN plan and confirm that the number of employees is within the approved capacity of the HCO.
(16) By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the physicians, providers or medical group practice in the MPN to provide treatment for injured workers in the workers' compensation system and that the contractual agreement with the providers is in compliance with Labor Code section 4609, if applicable.
(f) If the entity is a Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, in addition to the requirements set forth in subdivision (e) [excluding (e)(9) and (e)(15)], a Medical Provider Network application shall include the following information:
(1) The application shall set forth that the entity has a reasonable number of providers with competency in occupational medicine.
(A) The MPN applicant may show that a physician has competency by confirming that the physician either is Board Certified or was residency trained in that specialty.
(B) If (A) is not applicable, describe any other relevant procedure or process that assures that providers of medical treatment are competent to provide treatment for occupational injuries and illnesses.
(g) If the MPN applicant is providing for ancillary services within the MPN that are in addition to the services provided by the Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, it shall set forth the ancillary services in the application.
(h) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been approved as a MPN, and the entity does not maintain its certification or licensure or regulated status, then the entity must file a new Medical Provider Network Application pursuant to section 9767.3 (d).
(i) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been modified from its certification or licensure or regulated status, the application shall comply with subdivision (d).
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 3209.3, 4609, 4616, 4616.1, 4616.2, 4616.3, 4616.5 and 4616.7, Labor Code.
s 9767.4. Cover Page for Medical Provider Network Application.
[DWC Mandatory Form - Section 9767.4 - 09/15/05]
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 3700, 3743, 4616, 4616.5 and 4616.7, Labor Code.
s 9767.5. Access Standards.
(a) A MPN must have at least three physicians of each specialty expected to treat common injuries experienced by injured employees based on the type of occupation or industry in which the employee is engaged and within the access standards set forth in (b) and (c).
(b) A MPN must have a primary treating physician and a hospital for emergency health care services, or if separate from such hospital, a provider of all emergency health care services, within 30 minutes or 15 miles of each covered employee's residence or workplace.
(c) A MPN must have providers of occupational health services and specialists within 60 minutes or 30 miles of a covered employee's residence or workplace.
(d) If a MPN applicant believes that, given the facts and circumstances with regard to a portion of its service area, specifically rural areas including those in which health facilities are located at least 30 miles apart, the accessibility standards set forth in subdivisions (b) and/or (c) are unreasonably restrictive, the MPN applicant may propose alternative standards of accessibility for that portion of its service area. The MPN applicant shall do so by including the proposed alternative standards in writing in its plan approval application or in a notice of MPN plan modification. The alternative standards shall provide that all services shall be available and accessible at reasonable times to all covered employees.
(e)(1) The MPN applicant shall have a written policy for arranging or approving non-emergency medical care for: (A) a covered employee authorized by the employer to temporarily work or travel for work outside the MPN geographic service area when the need for medical care arises; (B) a former employee whose employer has ongoing workers' compensation obligations and who permanently resides outside the MPN geographic service area; and (C) an injured employee who decides to temporarily reside outside the MPN geographic service area during recovery.
(2) The written policy shall provide the employees described in subdivision (e)(1) above with the choice of at least three physicians outside the MPN geographic service area who either have been referred by the employee's primary treating physician within the MPN or have been selected by the MPN applicant. In addition to physicians within the MPN, the employee may change physicians among the referred physicians and may obtain a second and third opinion from the referred physicians.
(3) The referred physicians shall be located within the access standards described in paragraphs (c) and (d) of this section.
(4) Nothing in this section precludes a MPN applicant from having a written policy that allows a covered employee outside the MPN geographic service area to choose his or her own provider for non-emergency medical care.
(f) For non-emergency services, the MPN applicant shall ensure that an appointment for initial treatment is available within 3 business days of the MPN applicant's receipt of a request for treatment within the MPN.
(g) For non-emergency specialist services to treat common injuries experienced by the covered employees based on the type of occupation or industry in which the employee is engaged, the MPN applicant shall ensure that an appointment is available within 20 business days of the MPN applicant's receipt of a referral to a specialist within the MPN.
(h) If the primary treating physician refers the covered employee to a type of specialist not included in the MPN, the covered employee may select a specialist from outside the MPN.
(i) The MPN applicant shall have a written policy to allow an injured employee to receive emergency health care services from a medical service or hospital provider who is not a member of the MPN.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 4616 and 4616.3, Labor Code.
s 9767.6. Treatment and Change of Physicians Within MPN.
(a) When the injured covered employee notifies the employer or insured employer of the injury or files a claim for workers' compensation with the employer or insured employer, the employer or insurer shall arrange an initial medical evaluation with a MPN physician in compliance with the access standards set forth in section 9767.5.
(b) Within one working day after an employee files a claim form under Labor Code section 5401, the employer or insurer shall provide for all treatment, consistent with guidelines adopted by the Administrative Director pursuant to Labor Code section 5307.27 or, prior to the adoption of these guidelines, the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines (ACOEM), and for all injuries not covered by the ACOEM guidelines or guidelines adopted by the Administrative Director, authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based. The Administrative Director incorporates by reference the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines (ACOEM), 2nd Edition (2004), published by OEM Press. A copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts 01915 (www.oempress.com).
(c) The employer or insurer shall provide for the treatment with MPN providers for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is rejected. Until the date the claim is rejected, liability for the claim shall be limited to ten thousand dollars ($10,000).
(d) The insurer or employer shall notify the employee of his or her right to be treated by a physician of his or her choice within the MPN after the first visit with the MPN physician and the method by which the list of participating providers may be accessed by the employee.
(e) At any point in time after the initial medical evaluation with a MPN physician, the covered employee may select a physician of his or her choice from within the MPN. Selection by the covered employee of a treating physician and any subsequent physicians shall be based on the physician's specialty or recognized expertise in treating the particular injury or condition in question.
(f) The employer or insurer shall not be entitled to file a Petition for Change of Treating Physician, as set forth at section 9786, if a covered employee is treating with a physician within the MPN.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 4604.5, 4616, 4616.3, 5307.27 and 5401, Labor Code.
s 9767.7. Second and Third Opinions.
(a) If the covered employee disputes either the diagnosis or the treatment prescribed by the primary treating physician or the treating physician, the employee may obtain a second and third opinion from physicians within the MPN. During this process, the employee is required to continue his or her treatment with the treating physician or a physician of his or her choice within the MPN.
(b) If the covered employee disputes either the diagnosis or the treatment prescribed by primary treating physician or the treating physician, it is the employee's responsibility to: (1) inform the person designated by the employer or insurer that he or she disputes the treating physician's opinion and requests a second opinion (the employee may notify the person designated by the employer or insurer either in writing or orally); (2) select a physician or specialist from a list of available MPN providers; (3) make an appointment with the second opinion physician within 60 days; and (4) inform the person designated by the employer or insurer of the appointment date. It is the employer's or insurer's responsibility to (1) provide a regional area listing of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question and inform the employee of his or her right to request a copy of the medical records that will be sent to the second opinion physician; (2) contact the treating physician, provide a copy of the medical records or send the necessary medical records to the second opinion physician prior to the appointment date, and provide a copy of the records to the covered employee upon request; and (3) notify the second opinion physician in writing that he or she has been selected to provide a second opinion and the nature of the dispute with a copy to the employee. If the appointment is not made within 60 days of receipt of the list of the available MPN providers, then the employee shall be deemed to have waived the second opinion process with regard to this disputed diagnosis or treatment of this treating physician.
(c) If, after reviewing the covered employee's medical records, the second opinion physician determines that the employee's injury is outside the scope of his or her practice, the physician shall notify the person designated by the employer or insurer and employee so the employer or insurer can provide a new list of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question.
(d) If the covered employee disagrees with either the diagnosis or treatment prescribed by the second opinion physician, the injured employee may seek the opinion of a third physician within the MPN. It is the employee's responsibility to: (1) inform the person designated by the employer or insurer that he or she disputes the treating physician's opinion and requests a third opinion (the employee may notify the person designated by the employer or insurer either in writing or orally); (2) select a physician or specialist from a list of available MPN providers; and (3) make an appointment with the third opinion physician within 60 days; and (4) inform the person designated by the employer or insurer of the appointment date. It is the employer's or insurer's responsibility to (1) provide a regional area listing of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question and inform the employee of his or her right to request a copy of the medical records that will be sent to the third opinion physician; and (2) contact the treating physician, provide a copy of the medical records or send the necessary medical records to the third opinion physician prior to the appointment date, and provide a copy of the records to the covered employee upon request; and (3) notify the third opinion physician in writing that he or she has been selected to provide a third opinion and the nature of the dispute with a copy to the employee. If the appointment is not made within 60 days of receipt of the list of the available MPN providers, then the employee shall be deemed to have waived the third opinion process with regard to this disputed diagnosis or treatment of this treating physician.
(e) If, after reviewing the covered employee's medical records, the third opinion physician determines that the employee's injury is outside the scope of his or her practice, the physician shall notify the person designated by the employer or insurer and employee so the MPN can provide a new list of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question.
(f) The second and third opinion physicians shall each render his or her opinion of the disputed diagnosis or treatment in writing and offer alternative diagnosis or treatment recommendations, if applicable. Any recommended treatment shall be in accordance with Labor Code section 4616(e). The second and third opinion physicians may order diagnostic testing if medically necessary. A copy of the written report shall be served on the employee, the person designated by the employer or insurer, and the treating physician within 20 days of the date of the appointment or receipt of the results of the diagnostic tests, whichever is later.
(g) The employer or insurer shall permit the employee to obtain the recommended treatment within the MPN. The covered employee may obtain the recommended treatment by changing physicians to the second opinion physician, third opinion physician, or other MPN physician.
(h) If the injured covered employee disagrees with the diagnosis or treatment of the third opinion physician, the injured employee may file with the Administrative Director a request for an Independent Medical Review.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 4616(a) and 4616.3, Labor Code.
s 9767.8. Modification of Medical Provider Network Plan.
(a) The MPN applicant shall serve the Administrative Director with an original Notice of MPN Plan Modification with original signature, any necessary documentation, and a copy of the Notice and any necessary documentation before any of the following changes occur:
(1) A change of 10% or more in the number or specialty of providers participating in the network since the approval date of the previous MPN Plan application or modification.
(2) A change of 25% or more in the number of covered employees since the approval date of the previous MPN Plan application or modification.
(3) A material change in the continuity of care policy.
(4) A material change in the transfer of care policy.
(5) Change in policy or procedure that is used by the MPN to conduct "economic profiling of MPN providers" pursuant to Labor Code section 4616.1.
(6) Change in the name of the MPN.
(7) Change in geographic service area within the State of California.
(8) Change in how the MPN complies with the access standards.
(9) A material change in any of the employee notification materials required by section 9767.12.
(b) The MPN applicant shall serve the Administrative Director with a Notice of MPN Plan Modification within 5 business days of a change of the DWC liaison.
(c) The modification must be verified by an officer or employee of the MPN authorized to sign on behalf of the MPN applicant. The verification shall state: "I, the undersigned officer or employee of the MPN applicant, have read and signed this notice and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this notice is true and correct."
(d) Within 60 days of the Administrative Director's receipt of a Notice of MPN Plan Modification, the Administrative Director shall approve or disapprove the plan modification based on information provided in the Notice of MPN Plan Modification. The Administrative Director shall approve or disapprove a plan modification based on the requirements of Labor Code section 4616 et seq. and this article. If the Administrative Director has not acted on a plan within 60 days of submittal of a Notice of MPN Plan Modification, it shall be deemed approved. Except for (a)(6) and (b), modifications shall not be made until the Administrative Director has approved the plan or until 60 days have passed, which ever occurs first. If the Administrative Director disapproves of the MPN plan modification, he or she shall serve the MPN applicant with a Notice of Disapproval within 60 days of the submittal of a Notice of MPN Plan Modification.
(e) A MPN applicant denied approval of a MPN plan modification may either:
(1) Submit a new request addressing the deficiencies; or
(2) Request a re-evaluation by the Administrative Director.
(f) Any MPN applicant may request a re-evaluation of the denial by submitting with the Division, within 20 days of the issuance of the Notice of Disapproval, a written request for a re-evaluation with a detailed statement explaining the basis upon which a re-evaluation is requested. The request for re-evaluation shall be accompanied by supportive documentary material relevant to the specific allegations raised and shall be verified under penalty of perjury. The MPN application and modification at issue shall not be refiled; they shall be made part of the administrative record by incorporation by reference.
(g) The Administrative Director shall, within 45 days of the receipt of the request for a re-evaluation, either:
(1) Issue a Decision and Order affirming or modifying the Notice of Disapproval based on a failure to meet the procedural requirements of this section or based on a failure to meet the requirements of Labor Code section 4616 et seq. and this article; or
(2) Issue a Decision and Order revoking the Notice of Disapproval and issue an approval of the modification;
(h) The Administrative Director may extend the time specified in subdivision (h) within which to act upon the request for a re-evaluation for a period of 30 days and may order a party to submit additional documents or information.
(i) A MPN applicant may appeal the Administrative Director's decision and order regarding the MPN by filing, within twenty (20) days of the issuance of the decision and order, a petition at the district office of the Workers' Compensation Appeals Board closest to the MPN applicant's principal place of business, together with a Declaration of Readiness to Proceed. The petition shall set forth the specific factual and/or legal reason(s) for the appeal. A copy of the petition and of the Declaration of Readiness to Proceed shall be concurrently served on the Administrative Director.
(j) The MPN applicant shall use the following Notice of MPN Plan Modification form:
[DWC Mandatory Form - Section 9767.8 - 09/15/05]
Note: Authority cited: Sections 133, 4616(g) and 5300(f), Labor Code. Reference: Sections 3700, 3743, 4616, 4616.2 and 4616.5, Labor Code.
s 9767.9. Transfer of Ongoing Care into the MPN.
(a) If the injured covered employee's injury or illness does not meet the conditions set forth in (e)(1) through (e)(4), the injured covered employee may be transferred into the MPN for medical treatment.
(b) Until the injured covered employee is transferred into the MPN, the employee's physician may make referrals to providers within or outside the MPN.
(c) Nothing in this section shall preclude an insurer or employer from agreeing to provide medical care with providers outside of the MPN.
(d) If an injured covered employee is being treated for an occupational injury or illness by a physician or provider prior to coverage of a medical provider network, and the injured covered employee's physician or provider becomes a provider within the MPN that applies to the injured covered employee, then the employer or insurer shall inform the injured covered employee and his or her physician or provider if his/her treatment is being provided by his/her physician or provider under the provisions of the MPN.
(e) The employer or insurer shall authorize the completion of treatment for injured covered employees who are being treated outside of the MPN for an occupational injury or illness that occurred prior to the coverage of the MPN and whose treating physician is not a provider within the MPN, including injured covered employees who pre-designated a physician and do not fall within the Labor Code section 4600(d), for the following conditions:
(1) An acute condition. For purposes of this subdivision, an acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a duration of less than 90 days. Completion of treatment shall be provided for the duration of the acute condition.
(2) A serious chronic condition. For purposes of this subdivision, a serious chronic condition is a medical condition due to a disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over 90 days and requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be authorized for a period of time necessary, up to one year: (A) to complete a course of treatment approved by the employer or insurer; and (B) to arrange for transfer to another provider within the MPN, as determined by the insurer or employer. The one year period for completion of treatment starts from the date of the injured covered employee's receipt of the notification, as required by subdivision (f), of the determination that the employee has a serious chronic condition.
(3) A terminal illness. For purposes of this subdivision, a terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment shall be provided for the duration of a terminal illness.
(4) Performance of a surgery or other procedure that is authorized by the insurer or employer as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days from the MPN coverage effective date.
(f) If the employer or insurer decides to transfer the covered employee's medical care to the medical provider network, the employer or insurer shall notify the covered employee of the determination regarding the completion of treatment and the decision to transfer medical care into the medical provider network. The notification shall be sent to the covered employee's residence and a copy of the letter shall be sent to the covered employee's primary treating physician. The notification shall be written in English and Spanish and use layperson's terms to the maximum extent possible.
(g) If the injured covered employee disputes the medical determination under this section, the injured covered employee shall request a report from the covered employee's primary treating physician that addresses whether the covered employee falls within any of the conditions set forth in subdivisions (e)(1-4). The treating physician shall provide the report to the covered employee within twenty calendar days of the request. If the treating physician fails to issue the report, then the determination made by the employer or insurer referred to in (f) shall apply.
(h) If the employer or insurer or injured covered employee objects to the medical determination by the treating physician, the dispute regarding the medical determination made by the treating physician concerning the transfer of care shall be resolved pursuant to Labor Code section 4062.
(i) If the treating physician agrees with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in subdivisions (e)(1) through (e)(4), the transfer of care shall go forward during the dispute resolution process.
(j) If the treating physician does not agree with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in subdivisions (e)(1) through (e)(4), the transfer of care shall not go forward until the dispute is resolved.
Note: Authority cited: Sections 133, 4616(g), and 4062, Labor Code. Reference: Sections 4616 and 4616.2, Labor Code.
s 9767.10. Continuity of Care Policy.
(a) At the request of a covered employee, an insurer or employer that offers a medical provider network shall complete the treatment by a terminated provider as set forth in Labor Code sections 4616.2(d) and (e).
(b) An "acute condition," as referred to in Labor Code section 4616.2(d)(3)(A), shall have a duration of less than ninety days.
(c) "An extended period of time," as referred to in Labor Code section 4616.2(d)(3)(B) with regard to a serious and chronic condition, means a duration of at least ninety days.
(d) The MPN applicant's continuity of care policy shall include a dispute resolution procedure that contains the following requirements:
(1) Following the employer's or insurer's determination of the injured covered employee's medical condition, the employer or insurer shall notify the covered employee of the determination regarding the completion of treatment and whether or not the employee will be required to select a new provider from within the MPN. The notification shall be sent to the covered employee's residence and a copy of the letter shall be sent to the covered employee's primary treating physician. The notification shall be written in English and Spanish and use layperson's terms to the maximum extent possible.
(2) If the terminated provider agrees to continue treating the injured covered employee in accordance with Labor Code section 4616.2 and if the injured covered employee disputes the medical determination, the injured covered employee shall request a report from the covered employee's primary treating physician that addresses whether the covered employee falls within any of the conditions set forth in Labor Code section 4616.2(d)(3); an acute condition; a serious chronic condition; a terminal illness; or a performance of a surgery or other procedure that is authorized by the insurer or employer as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contract's termination date. The treating physician shall provide the report to the covered employee within twenty calendar days of the request. If the treating physician fails to issue the report, then the determination made by the employer or insurer referred to in (d)(1) shall apply.
(3) If the employer or insurer or injured covered employee objects to the medical determination by the treating physician, the dispute regarding the medical determination made by the treating physician concerning the continuity of care shall be resolved pursuant to Labor Code section 4062.
(4) If the treating physician agrees with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in Labor Code section 4616.2(d)(3), the employee shall choose a new provider from within the MPN during the dispute resolution process.
(5) If the treating physician does not agree with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in Labor Code section 4616.2(d)(3), the injured covered employee shall continue to treat with the terminated provider until the dispute is resolved.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Section 4616.2, Labor Code.
s 9767.11. Economic Profiling Policy.
(a) An insurer's or employer's filing of its economic profiling policies and procedures shall include:
(1) An overall description of the profiling methodology, data used to create the profile and risk adjustment;
(2) A description of how economic profiling is used in utilization review;
(3) A description of how economic profiling is used in peer review; and
(4) A description of any incentives and penalties used in the program and in provider retention and termination decisions.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Section 4616.1, Labor Code.
s 9767.12. Employee Notification.
(a) An employer or insurer that offers a Medical Provider Network Plan under this article shall notify each covered employee in writing about the use of the Medical Provider Network 30 days prior to the implementation of an approved MPN, at the time of hire, or when an existing employee transfers into the MPN, whichever is appropriate to ensure that the employee has received the initial notification. The notification shall also be sent to a covered employee at the time of injury. The notification(s) shall be written in English and Spanish. The initial written notification shall include the following information:
(1) How to contact the person designated by the employer or insurer to be the MPN contact for covered employees. The employer or insurer shall provide a toll free telephone number of the MPN geographical service area includes more than one area code;
(2) A description of MPN services;
(3) How to review, receive or access the MPN provider directory. Nothing precludes an employer or insurer from initially providing covered employees with a regional area listing of MPN providers in addition to maintaining and making available its complete provider listing in writing. If the provider directory is also accessible on a website, the URL address shall be listed;
(4) How to access initial care and subsequent care, and what the access standards are under section 9767.5;
(5) How to access treatment if (A) the employee is authorized by the employer to temporarily work or travel for work outside the MPN's geographical service area; (B) a former employee whose employer has ongoing workers' compensation obligations permanently resides outside the MPN geographical service area; and (C) an injured employee decides to temporarily reside outside the MPN geographical service area during recovery;
(6) How to choose a physician within the MPN;
(7) What to do if a covered employee has trouble getting an appointment with a provider within the MPN;
(8) How to change a physician within the MPN;
(9) How to obtain a referral to a specialist within the MPN or outside the MPN, if needed;
(10) How to use the second and third opinion process;
(11) How to request and receive an independent medical review;
(12) A description of the standards for transfer of ongoing care into the MPN and a notification that a copy of the policy shall be provided to an employee upon request; and
(13) A description of the continuity of care policy and a notification that a copy of the policy shall be provided to an employee upon request.
(b) At the time of the selection of the physician for a third opinion, the covered employee shall be notified about the Independent Medical Review process. The notification shall be written in English and Spanish.
(c) Covered employees shall be notified 30 days prior to a change of the medical provider network. If the MPN applicant is an insurer, then a copy of the notification shall be served on the insured employer. The notification shall be written in English and Spanish.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616, 4616.2 and 4616.3, Labor Code.
s 9767.13. Denial of Approval of Application and Re-Evaluation.
(a) The Administrative Director shall deny approval of a plan if the MPN applicant does not satisfy the requirements of this article and Labor Code section 4616 et seq. and shall state the reasons for disapproval in writing in a Notice of Disapproval, and shall transmit the Notice to the MPN applicant by U.S. Mail.
(b) An MPN applicant denied approval may either:
(1) Submit a new application addressing the deficiencies; or
(2) Request a re-evaluation by the Administrative Director.
(c) Any MPN applicant may request a re-evaluation by submitting with the Division, within 20 days of the issuance of the Notice of Disapproval, a written request for re-evaluation with a detailed statement explaining the basis upon which a re-evaluation is requested. The request for a re-evaluation shall be accompanied by supportive documentary material relevant to the specific allegations raised and shall be verified under penalty of perjury. The MPN application at issue shall not be re-filed; it shall be made part of the administrative record by incorporation by reference.
(d) The Administrative Director shall, within 45 days of the receipt of the request for a re-evaluation, either:
(1) Issue a Decision and Order affirming or modifying the Notice of Disapproval based on a failure to meet the procedural requirements of this section or based on a failure to meet the requirements of Labor Code section 4616 et seq. and this article; or
(2) Issue a Decision and Order revoking the Notice of Disapproval and issue an approval of the MPN.
(e) The Administrative Director may extend the time specified in subdivision (d) within which to act upon the request for a re-evaluation for a period of 30 days and may order a party to submit additional documents or information.
(f) A MPN applicant may appeal the Administrative Director's decision and order regarding the MPN by filing, within twenty (20) days of the issuance of the decision and order, a petition at the district office of the Workers' Compensation Appeals Board closest to the MPN applicant's principal place of business, together with a Declaration of Readiness to Proceed. The petition shall set forth the specific factual and/or legal reason(s) for the appeal. A copy of the petition and of the Declaration of Readiness to Proceed shall be concurrently served on the Administrative Director.
Note: Authority cited: Sections 133, 4616(g) and 5300(f), Labor Code. Reference: Section 4616, Labor Code.
s 9767.14. Suspension or Revocation of Medical Provider Network Plan; Hearing.
(a) The Administrative Director may suspend or revoke approval of a MPN Plan if:
(1) Service under the MPN is not being provided according to the terms of the approved MPN plan.
(2) The MPN fails to meet the requirements of Labor Code section 4616 et seq. and this article.
(3) False or misleading information is knowingly or repeatedly submitted by the MPN or a participating provider or the MPN knowingly or repeatedly fails to report information required by this article.
(4) The MPN knowingly continues to use the services of a provider or medical reviewer whose license, registration, or certification has been suspended or revoked or who is otherwise ineligible to provide treatment to an injured worker under California law.
(b) If one of the circumstances in subdivision (a) exists, the Administrative Director shall notify the MPN applicant in writing of the specific deficiencies alleged. The Administrative Director shall allow the MPN applicant an opportunity to correct the deficiency and/or to respond within ten days. If the Administrative Director determines that the deficiencies have not been cured, he or she shall issue a Notice of Action to the MPN applicant that specifies the time period in which the suspension or revocation will take effect and shall transmit the Notice of Action to the MPN applicant by U.S. Mail.
(c) A MPN applicant may request a re-evaluation of the suspension or revocation by submitting to the Administrative Director, within 20 days of the issuance of the Notice of Action, a written notice of the request for a re-evaluation with a detailed statement explaining the basis upon which a re-evaluation is requested. The request for a re-evaluation shall be accompanied by supportive documentary material relevant to the specific allegations raised and shall be verified under penalty of perjury. The MPN application at issue shall not be re-filed; it shall be made part of the administrative record and incorporated by reference.
(d) The Administrative Director shall, within 45 days of the receipt of the request for a re-evaluation, either:
(1) Issue a Decision and Order affirming or modifying the Notice of Action based on a failure to meet the procedural requirements of this section or based on a failure to meet the requirements of Labor Code section 4616 et seq. and this article;
(2) Issue a Decision and Order revoking the Notice of Action;
(e) The Administrative Director may extend the time specified in subdivision (d) within which to act upon the request for a re-evaluation for a period of 30 days and may order a party to submit additional documents or information.
(f) A MPN applicant may appeal the Administrative Director's decision and order regarding the MPN by filing, within twenty (20) days of the issuance of the decision and order, a petition at the district office of the Workers' Compensation Appeals Board closest to the MPN applicant's principal place of business, together with a Declaration of Readiness to Proceed. The petition shall set forth the specific factual and/or legal reason(s) for the appeal. A copy of the petition and of the Declaration of Readiness to Proceed shall be concurrently served on the Administrative Director.
Note: Authority cited: Sections 133, 4616(g) and 5300(f), Labor Code. Reference: Section 4616, Labor Code.
s 9767.15. Compliance with Permanent MPN Regulations.
a. This section applies to MPNs that were approved by the Administrative Director pursuant to the emergency Medical Provider Network regulations effective November 1, 2004
b. Employers or insurers whose MPNs were approved pursuant to the emergency Medical Provider Network regulations are not required to submit a Notice of MPN Plan Modification to comply with the new or revised sections of the permanent regulations, including:
1. Section 9767.3(d)(8)(C) or Section 9767.3(d)(16) regarding the contractual agreements contained in the Application for a Medical Provider Network Plan provisions.
2. Sections 9767.5(e)(1), (e)(2), (e)(3), (e)(4), 9767.5(h) and 9767.5(i) of the Access Standards provisions.
3. Section 9767.9(g) provision providing a timeline for the treating physician's report and what happens if the treating physician fails to issue a timely report contained in the Transfer of Ongoing Care into the MPN provisions.
4. Section 9767.10(b)(c) and (d) of the Continuity of Care provisions.
5. Section 9767.12(a), (a)(1), (a)(2), (a)(3), (a)(4) and (a)(5) of the Employee Notification provisions.
c. At the time an employer or insurer with an approved MPN pursuant to the emergency Medical Provider Network regulations submits a Notice of MPN Plan Modification, the employer or insurer shall be required to verify compliance with the sections of the MPN permanent regulations listed in subdivision (b) above.
Note: Authority cited: Sections 133, 4616(g) and 5300(f), Labor Code. Reference: Sections 4609, 4616, 4616.2 and 4616.3, Labor Code.
s 9768.1. Definitions.
(a) As used in this article, the following definitions apply:
(1) "American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines" ( "ACOEM") means the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, 2nd Edition (2004), published by OEM Press. The Administrative Director incorporates ACOEM by reference. A copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts 01915 (www.oempress.com).
(2) "Appropriate specialty" means a medical specialty in an area or areas appropriate to the condition or treatment under review.
(3) "Independent Medical Reviewer" ( "IMR") means the physician who is randomly selected pursuant to subdivision (b) of Labor Code section 4616.4.
(4) "In-person examination" means an examination of an injured employee by a physician which involves more than a review of records, and may include a physical examination, discussing the employee's medical condition with the employee, taking a history and performing an examination.
(5) "Material familial affiliation" means a relationship in which one of the persons or entities listed in section 9768.2 is the parent, child, grandparent, grandchild, sibling, uncle, aunt, nephew, niece, spouse, or cohabitant of the Independent Medical Reviewer.
(6) "Material financial affiliation" means a financial interest (owns a legal or equitable interest of more than 1% interest in the party, or a fair market value in excess of $2000, or relationship of director, advisor, or active participant) in any person or entity listed in section 9768.2. It also means any gift or income of more than $300 in the preceding year except for income for services as a second opinion physician, third opinion physician, treating physician, Agreed Medical Evaluator, Qualified Medical Evaluator, or Independent Medical Reviewer.
(7) "Material professional affiliation" means any relationship in which the Independent Medical Reviewer shares office space with, or works in the same office of, any person or entity listed in section 9768.2.
(8) "Medical emergency" means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy.
(9) "Medical Provider Network Contact" ( "MPN Contact") means the individual(s) designated by the MPN Applicant in the employee notification who is responsible for answering employees' questions about the Medical Provider Network and is responsible for assisting the employee in arranging for an Independent Medical Review.
(10) "Panel" means the contracted providers in a specific specialty.
(11) "Relevant medical records" means all information that was considered in relation to the disputed treatment or diagnostic service, including: (A) a copy of all correspondence from, and received by, any treating physician who provided a treatment or diagnostic service to the injured employee in connection with the injury; (B) a complete and legible copy of all medical records and other information used by the physicians in making a decision regarding the disputed treatment or diagnostic service; (C) the treating physician's report with the disputed treatment or diagnosis; and (D) the second and third opinion physicians' reports.
(12) "Residence" means the covered employee's primary residence.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.2. Conflicts of Interest.
(a) The IMR shall not have any material, professional, familial, or financial affiliation with any of the following:
(1) The injured employee's employer or employer's workers' compensation insurer;
(2) Any officer, director, management employee, or attorney of the injured employee's medical provider network, employer or employer's workers' compensation insurer;
(3) Any treating health care provider proposing the service or treatment;
(4) The institution at which the service or treatment would be provided, if known;
(5) The development or manufacture of the principal drug, device, procedure, or other therapy proposed for the injured employee whose treatment is under review; or
(6) The injured employee, the injured employee's immediate family, or the injured employee's attorney.
(b) The IMR shall not have a contractual agreement to provide physician services for the injured employee's MPN if the IMR is within a 35 mile radius of the treating physician.
(c) The IMR shall not have previously treated or examined the injured employee.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.3. Qualifications of Independent Medical Reviewers.
(a) To qualify to be on the Administrative Director's list of Independent Medical Reviewers, a physician shall file a Physician Contract Application pursuant to section 9768.5 that demonstrates to the satisfaction of the Administrative Director that the physician:
(1) Is board certified. For physicians, the Administrative Director shall recognize only specialty boards recognized by the appropriate California licensing board.
(2) Has an unrestricted license as a physician in California under the appropriate licensing Board;
(3) Is not currently under accusation by any governmental licensing agency for a quality of care violation, fraud related to medical practice, or felony conviction or conviction of a crime related to the conduct of his or her practice of medicine;
(4) Has not been terminated or had discipline imposed by the Industrial Medical Council or Administrative Director in relation to the physician's role as a Qualified Medical Evaluator; is not currently under accusation by the Industrial Medical Council or Administrative Director; has not been denied renewal of Qualified Medical Evaluator status, except for non-completion of continuing education or for non-payment of fees; has neither resigned nor failed to renew Qualified Medical Evaluator status while under accusation or probation by the Industrial Medical Council or Administrative Director or after notification that reappointment as a Qualified Medical Evaluator may or would be denied for reasons other than non-completion of continuing education or non-payment of fees; and has not filed any applications or forms with the Industrial Medical Council or Administrative Director which contained any untrue material statements;
(5) Has not been convicted of a felony crime or a crime related to the conduct of his or her practice of medicine; and
(6) Has no history of disciplinary action or sanction, including but not limited to, loss of staff privileges or participation restrictions taken or pending by any hospital, government or regulatory body.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.4. IMR Contract Application Procedures.
(a) A physician seeking to serve as an Independent Medical Reviewer shall:
(1) Apply to the Administrative Director on the Physician Contract Application set forth in section 9768.5.
(2) Furnish a certified copy of his or her board certification, a copy of his or her current license to practice medicine, and submit other documentation of his or her qualifications as the Administrative Director may require. (continued)