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(3) Designate specialties based on each of his or her board certifications.
(4) Designate the address(es) of the physician's office with necessary medical equipment where in-person examinations will be held.
(5) Agree to see any injured worker assigned to him or her within 30 days unless there is a conflict of interest as defined in section 9768.2.
(6) During the application process and after being notified by the Administrative Director that the contract application has been accepted, the physician shall keep the Administrative Director informed of any change of address, telephone, email address or fax number, and of any disciplinary action taken by a licensing board.
(b) The contract application, completed by the physician, and any supporting documentation included with the contract application, shall be filed at the Administrative Director's office listed on the form. The contract application submitted by the physician may be rejected if it is incomplete, contains false information or does not contain the required supporting documentation listed in this section.
(c) The Administrative Director shall maintain a list of physicians who have applied, and whom the Administrative Director has contracted with to conduct Independent Medical Reviews under Labor Code section 4616.4.
(d) The IMR contract term is two years. A physician may apply to serve for subsequent two year terms by following the procedure set forth in subdivision (a).
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.5. Physician Contract Application Form.
(Note to physicians: please use three letter specialty code when completing block 3 of application form)
SPECIALTY CODES MAI Allergy and Immunology MAA Anesthesiology MRS Colon & Rectal Surgery MDE Dermatology MEM Emergency Medicine MFP Family Practice MPM General Preventive Medicine MOSU Hand - Orthopaedic Surgery, Plastic Surgery, General Surgery MMM Internal Medicine MMV Internal Medicine - Cardiovascular Disease MME Internal Medicine - Endocrinology Diabetes and Metabolism MMG Internal Medicine - Gastroenterology MMH Internal Medicine - Hematology MMI Internal Medicine - Infectious Disease MMO Internal Medicine - Medical Oncology MMN Internal Medicine - Nephrology MMP Internal Medicine - Pulmonary Disease MMR Internal Medicine - Rheumatology MPN Neurology MNS Neurological Surgery MNM Nuclear Medicine MOG Obstetrics and Gynecology MPO Occupational Medicine MOP Opthalmology MOSG Orthopaedic Surgery (General) MOSS Orthopaedic - Shoulder MOSK Orthopaedic - Knee MOSB Orthopaedic - Spine MOSF Orthopaedic - Foot and ankle MTO Otolaryngology MAP Pain Management - Psychiatry and Neurology, Physical Medicine and Rehabilitation, Anesthesiology MHA Pathology MEP Pediatrics MPR Physical Medicine & Rehabilitation MPS Plastic Surgery MPD Psychiatry MSY Surgery MSG Surgery - General Vascular MTS Thoracic Surgery MTO Toxicology - Preventive Medicine, Pediatrics, Emergency MUU Urology MRD Radiology POD Podiatry DWC Form 9768.5 1/1/05
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.6. Administrative Director's Action on Contract Application Submitted by Physician.
(a) After reviewing a completed contract application submitted by a physician, if the Administrative Director finds that the physician meets the qualifications, he/she shall accept the contract application made by the physician to be an Independent Medical Reviewer by executing the IMR contract, notify the physician by mail, and add the physician's name to the list of Independent Medical Reviewers. The contract term shall be for a two-year term beginning with the date of acceptance by the Administrative Director.
(b) If the Administrative Director determines that a physician does not meet the qualifications, he/she shall notify the physician by mail that the physician's contract application is not accepted and the reason for the rejection.
(c) A physician whose contract application has not been accepted may reapply.
(d) If the Administrative Director denies a physician's contract application following at least two subsequent submissions, the physician may seek further review of the Administrative Director's decision by filing an appeal with the Workers' Compensation Appeals Board, and serving a copy on the Administrative Director, within twenty days after receipt of the denial.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.4 and 5300(f), Labor Code.
s 9768.7. IMR Request to Be Placed on Voluntary Inactive Status.
A physician may request to be placed on the inactive list during the IMR contract term. The physician shall submit the request to the Administrative Director and specify the time period that he or she is requesting to be on voluntary inactive status. The two-year contract term is not extended due to a physician's request to be placed on voluntary inactive status.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.8. Removal of Physicians from Independent Medical Reviewer List.
(a) The Administrative Director may cancel the IMR contract and remove a physician from the Independent Medical Reviewer list if the Administrative Director determines based upon the Administrative Director's monitoring of reports:
(1) That the physician, having been notified by the Administrative Director of the physician's selection to render an Independent Medical Review, has not issued the Independent Medical Review report in a case within the time limits prescribed in these regulations on more than one occasion; or
(2) That the physician has not met the reporting requirements on more than one occasion; or
(3) That the physician has at any time failed to disclose to the Administrative Director that the physician had a conflict of interest pursuant to section 9768.2; or
(4) That the physician has failed to schedule appointments within the time frame required by these regulations on more than one occasion; or
(5) That the physician has failed to maintain the confidentiality of medical records and the review materials consistent with the applicable state and federal law.
(b) The Administrative Director shall cancel the IMR contract and remove a physician from the Independent Medical Reviewer list if the Administrative Director determines:
(1) That the physician no longer meets the qualifications to be on the list; or
(2) That the physician's contract application to be on the list contained material statements which were not true.
(c) The Administrative Director shall place a physician on an inactive list for up to the end of the two year contract term whenever the Administrative Director determines that the appropriate licensing Board from whom the physician is licensed has filed an accusation for a quality of care violation, fraud related to medical practice, or conviction of a felony crime or a crime related to the conduct of his or her practice of medicine against the physician or taken other action restricting the physician's medical license. If the accusation or action is later withdrawn, dismissed or determined to be without merit during the two year contract term, the physician shall advise the Administrative Director who will then remove the physician's name from the inactive list. If the accusation or action is withdrawn, dismissed or determined to be without merit after the expiration of the two year contract term, the physician may reapply to serve as an Independent Medical Reviewer pursuant to section 9768.4.
(d) Upon removal of a physician from the Independent Medical Reviewer list or placement on the inactive list, the Administrative Director shall advise the physician by mail of the removal or placement on the inactive list, the Administrative Director's reasons for such action, and the right to request a hearing on the removal from the IMR list or placement on the inactive list.
(e) A physician who has been mailed a notice of removal from the list or placement on the inactive list, may, within 30 calendar days of the mailing of the notice, request a hearing by filing a written request for hearing with the Administrative Director. If a written request for hearing is not received by the Administrative Director within 30 calendar days of the mailing of the notice, the physician shall be deemed to have waived any appeal or request for hearing.
(f) Upon receipt of a written request for hearing, the Administrative Director shall prepare an accusation and serve the applicant physician with the accusation, as provided in Government Code section 11503.
(g) Hearings shall be held by the Administrative Director or his or her designee under the procedures of Chapter 5 of Part 1 of Division 3 of Title 2 of the Government Code (commencing with section 11500) and the regulations of the Office of Administrative Hearings (Title 1, California Code of Regulations, section 1000 et seq.).
(h) Failure to timely file a notice of defense or failure to appear at a noticed hearing or conference shall constitute a waiver of a right to a hearing.
(i) A physician who has been removed from the list may petition for reinstatement after one year has elapsed since the effective date of the Administrative Director's decision on the physician's removal. The provisions of Government Code section 11522 shall apply to such petition.
Note: Authority cited: Sections 133 and 4616, Labor Code; and Section 11400.20, Government Code. Reference: Section 4616.4, Labor Code; and Sections 11415.10, 11503 and 11522, Government Code.
s 9768.9. Procedure for Requesting an Independent Medical Review.
(a) If a covered employee disputes the diagnostic service, diagnosis, or medical treatment prescribed by the second opinion physician, the injured employee may seek the opinion of a third physician in the MPN. The covered employee and the employer or insurer shall comply with the requirements of section 9767.7(d). Additionally, at the time of the selection of the physician for a third opinion, the MPN Contact shall notify the covered employee about the Independent Medical Review process and provide the covered employee with an "Independent Medical Review Application" form set forth in section 9768.10. The MPN Contact shall fill out the "MPN Contact Section" of the form and list the specialty of the treating physician and an alternative specialty, if any, that is different from the specialty of the treating physician.
(b) If a covered employee disputes either the diagnostic service, diagnosis or medical treatment prescribed by the third opinion physician, the covered employee may request an Independent Medical Review by filing the completed Independent Medical Review Application form with the Administrative Director. The covered employee shall complete the "employee section" of the form, indicate on the form whether he or she requests an in-person examination or record review, and may list an alternative specialty, if any, that is different from the specialty of the treating physician.
(c) The Administrative Director shall select an IMR with an appropriate specialty within ten business days of receiving the Independent Medical Review Application form. The Administrative Director's selection of the IMR shall be based on the specialty of the treating physician, the alternative specialties listed by the covered employee and the MPN Contact, and the information submitted with the Independent Medical Review Application.
(d) If the covered employee requests an in-person examination, the Administrative Director shall randomly select a physician from the panel of available Independent Medical Reviewers, with an appropriate specialty, who has an office located within thirty miles of the employee's residence address, to be the Independent Medical Reviewer. If there is only one physician with an appropriate specialty within thirty miles of the employee's residence address, that physician shall be selected to be the Independent Medical Reviewer. If there are no physicians with an appropriate specialty who have offices located within thirty miles of the employee's residence address, the Administrative Director shall search in increasing five mile increments, until one physician is located. If there are no available physicians with this appropriate specialty, the Administrative Director may choose another specialty based on the information submitted.
(e) If the covered employee requests a record review, then the Administrative Director shall randomly select a physician with an appropriate specialty from the panel of available Independent Medical Reviewers to be the IMR. If there are no physicians with an appropriate specialty, the Administrative Director may choose another specialty based on the information submitted.
(f) The Administrative Director shall send written notification of the name and contact information of the IMR to the covered employee, the employee's attorney, if any, the MPN Contact and the IMR. The Administrative Director shall send a copy of the completed Independent Medical Review Application to the IMR.
(g) The covered employee, MPN Contact, or the selected IMR can object within 10 calendar days of receipt of the name of the IMR to the selection if there is a conflict of interest as defined by section 9768.2. If the IMR determines that he or she does not practice the appropriate specialty, the IMR shall withdraw within 10 calendar days of receipt of the notification of selection. If this conflict is verified or the IMR withdraws, the Administrative Director shall select another IMR from the same specialty. If there are no available physicians with the same specialty, the Administrative Director may select an IMR with another specialty based on the information submitted and in accordance with the procedure set forth in subdivision (d) for an in-person examination and subdivision (e) for a record review.
(h) If the covered employee requests an in-person exam, within 60 calendar days of receiving the name of the IMR, the covered employee shall contact the IMR to arrange an appointment. If the covered employee fails to contact the IMR for an appointment within 60 calendar days of receiving the name of the IMR, then the employee shall be deemed to have waived the IMR process with regard to this disputed diagnosis or treatment of this treating physician. The IMR shall schedule an appointment with the covered employee within 30 calendar days of the request for an appointment, unless all parties agree to a later date. The IMR shall notify the MPN Contact of the appointment date.
(i) The covered employee shall provide written notice to the Administrative Director and the MPN Contact if the covered employee decides to withdraw the request for an Independent Medical Reviewer.
(j) During this process, the employee shall remain within the MPN for treatment pursuant to section 9767.6.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.3 and 4616.4, Labor Code.
s 9768.10. Independent Medical Review Application (Form).
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.3 and 4616.4, Labor Code.
s 9768.11. In-Person Examination or Record Review IMR Procedure.
(a) The MPN Contact shall send all relevant medical records to the IMR. The MPN Contact shall also send a copy of the documents to the covered employee. The employee may furnish any relevant medical records or additional materials to the Independent Medical Reviewer, with a copy to the MPN Contact. If an in-person examination is requested and if a special form of transportation is required because of the employee's medical condition, it is the obligation of the MPN Contact to arrange for it. The MPN Contact shall furnish transportation and arrange for an interpreter, if necessary, in advance of the in-person examination. All reasonable expenses of transportation shall be incurred by the insurer or employer pursuant to Labor Code section 4600. Except for the in-person examination itself, the Independent Medical Reviewer shall have no ex parte contact with any party. Except for matters dealing with scheduling appointments, scheduling medical tests and obtaining medical records, all communications between the Independent Medical Reviewer and any party shall be in writing, with copies served on all parties.
(b) If the IMR requires further tests, the IMR shall notify the MPN Contact within one working day of the appointment. All tests shall be consistent with the medical treatment utilization schedule adopted pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines, and for all injuries not covered by the medical treatment utilization schedule or the ACOEM guidelines, in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.
(c) The IMR may order any diagnostic tests necessary to make his or her determination regarding medical treatment or diagnostic services for the injury or illness but shall not request the employee to submit to an unnecessary exam or procedure. If a test duplicates a test already given, the IMR shall provide justification for the duplicative test in his or her report.
(d) If the employee fails to attend an examination with the IMR and fails to reschedule the appointment within five business days of the missed appointment, the IMR shall perform a review of the record and make a determination based on those records.
(e) The IMR shall serve the report on the Administrative Director, the MPN Contact, the employee and the employee's attorney, if any, within 20 days after the in-person examination or completion of the record review.
(f) If the disputed health care service has not been provided and the IMR certifies in writing that an imminent and serious threat to the health of the injured employee exists, including, but not limited to, the potential loss of life, limb, or bodily function, or the immediate and serious deterioration of the injured employee, the report shall be expedited and rendered within three business days of the in-person examination by the IMR.
(g) Subject to approval by the Administrative Director, reviews not covered under subdivision (f) may be extended for up to three business days in extraordinary circumstances or for good cause.
(h) Extensions for good cause shall be granted for:
(1) Medical emergencies of the IMR or the IMR's family;
(2) Death in the IMR's family; or
(3) Natural disasters or other community catastrophes that interrupt the operation of the IMR's office operations.
(i) Utilizing the medical treatment utilization schedule established pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines, and taking into account any reports and information provided, the IMR shall determine whether the disputed health care service is consistent with the recommended standards. For injuries not covered by the medical treatment utilization schedule or by the ACOEM guidelines, the treatment rendered shall be in accordance with other evidence-based medical treatment guidelines which are generally recognized by the national medical community and scientifically based.
(j) The IMR shall not treat or offer to provide medical treatment for that injury or illness for which he or she has done an Independent Medical Review evaluation for the employee unless a medical emergency arises during the in-person examination.
(k) Neither the employee nor the employer nor the insurer shall have any liability for payment for the Independent Medical Review which was not completed within the required timeframes unless the employee and the employer each waive the right to a new Independent Medical Review and elect to accept the original evaluation.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.4 and 5307.27, Labor Code.
s 9768.12. Contents of Independent Medical Review Reports.
(a) Reports of Independent Medical Reviewers shall include:
(1) The date of the in-person examination or record review;
(2) The patient's complaint(s);
(3) A listing of all information received from the parties reviewed in preparation of the report or relied upon for the formulation of the physician's opinion;
(4) The patient's medical history relevant to the diagnostic services, diagnosis or medical treatment;
(5) Findings on record review or in-person examination;
(6) The IMR's diagnosis;
(7) The physician's opinion whether or not the proposed treatment or diagnostic services are appropriate and indicated. If the proposed treatment or diagnostic services are not appropriate or indicated, any alternative diagnosis or treatment recommendation consistent with the medical treatment utilization schedule shall be included;
(8) An analysis and determination whether the disputed health care service is consistent with the medical treatment utilization schedule established pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines. For injuries not covered by the medical treatment utilization schedule or by the ACOEM guidelines, an analysis and determination whether the treatment rendered is in accordance with other evidence-based medical treatment guidelines which are generally recognized by the national medical community and scientifically based; and
(9) The signature of the physician.
(b) The report shall be in writing and use layperson's terms to the maximum extent possible.
(c) An Independent Medical Reviewer shall serve with each report the following executed declaration made under penalty of perjury:
"I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code section 139.3. __________ __________" Date Signature
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 139.3, 4616.4 and 5307.27, Labor Code.
s 9768.13. Destruction of Records by the Administrative Director.
The Administrative Director may destroy any forms or documents submitted to the Administrative Director as part of the IMR process two years after the date of receipt.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.14. Retention of Records by Independent Medical Reviewer.
Each Independent Medical Reviewer shall retain all comprehensive medical reports completed by the Independent Medical Reviewer for a period of five years from the date of the IMR report.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.15. Charges for Independent Medical Reviewers.
(a) Payment for the services of the Independent Medical Reviewers shall be made by the employer or insurer.
(b) The fee shall be based on the Official Medical Fee Schedule using confirmatory consultation codes (99271 through 99275 for in-person examinations or 99271 through 99273 for evaluations not requiring an in-person examination), 99080 for reports, and 99358 for record reviews, and any other appropriate codes or modifiers.
(c) An IMR shall not accept any additional compensation from any source for his or her services as an IMR except for services provided to treat a medical emergency that arose during an in-person examination pursuant to section 9768.11(j).
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.
s 9768.16. Adoption of Decision.
(a) The Administrative Director shall immediately adopt the determination of the Independent Medical Reviewer and issue a written decision within 5 business days of receipt of the report.
(b) The parties may appeal the Administrative Director's written decision by filing a petition with the Workers' Compensation Appeals Board and serving a copy on the Administrative Director, within twenty days after receipt of the decision.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.4 and 5300(f), Labor Code.
s 9768.17. Treatment Outside the Medical Provider Network.
(a) If the IMR agrees with the diagnosis, diagnostic service or medical treatment prescribed by the treating physician, the covered employee shall continue to receive medical treatment from physicians within the MPN.
(b) If the IMR does not agree with the disputed diagnosis, diagnostic service or medical treatment prescribed by the treating physician, the covered employee shall seek medical treatment with a physician of his or her choice either within or outside the MPN. If the employee chooses to receive medical treatment with a physician outside the MPN, the treatment is limited to the treatment recommended by the IMR or the diagnostic service recommended by the IMR.
(c) The medical treatment shall be consistent with the medical treatment utilization schedule established pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines. For injuries not covered by the medical treatment utilization schedule or by the ACOEM guidelines, the treatment rendered shall be in accordance with other evidence-based medical treatment guidelines which are generally recognized by the national medical community and scientifically based.
(d) The employer or insurer shall be liable for the cost of any approved medical treatment in accordance with Labor Code section 5307.1 or 5307.11.
Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.4, 5307.1, 5307.11 and 5307.27, Labor Code.
s 9770. Definitions.
(a) "Administrative Director" means the administrative director of the Division of Workers' Compensation.
(b) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(c) "Division" means the Division of Workers' Compensation.
(d) "Employer" means an employer as defined in Section 3300 of the Labor Code.
(e) "HCO Enrollee" means a person who is eligible to receive services from an HCO.
(f) "Health care organization" ( "HCO") means any entity certified as a health care organization by the administrative director pursuant to Section 4600.5 of the Labor Code and this article.
(g) "International Classification of Diseases -9th Revision (ICD-9) code" means the 4 or 5 digit number which identifies the illness, injury, disease, cause of death, or other morbid state of an enrollee that corresponds to the numeric classifications and descriptions listed in International Classification of Diseases. Clinical Modification. 9th Revision (ICD-9CM) US Department of Health and Human Services, Health Care Financing Administration. Washington DC: Superintendent of Documents, and updated successor revised manuals.
(h) "Material": A factor is "material" with respect to a matter if it is one to which a reasonable person would attach importance in determining the action to be taken upon the matter.
(i) "Participating provider" means a provider who is employed by or under contract with an HCO for purposes of providing occupational medical or health services or services required by this article.
(j) "Patient" means an HCO enrollee who is currently obtaining treatment or services for a work-related injury or illness.
(k) "Primary treating physician" means the treating physician primarily responsible for managing the care of the injured worker in accordance with Section 9785.5.
(l) "Professionally recognized standards of care" means health care practice encompassing the learning, skill and clinical judgment ordinarily possessed and and used by a provider of good standing in similar circumstances.
(m) "Provider" means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services.
(n) "Revocation" means the termination of a health care organization's certification to provide services pursuant to Section 4600.5 of the Labor Code and this article.
(o) "Standard Industrial Classification code" means the 4 digit number which identifies the primary type of economic activity which the employer is engaged in that corresponds to the numeric classifications and descriptions listed in The Standard Industrial Classification Manual 1987, Office of Management and Budget, Washington DC: Superintendent of Documents, US Government Printing Office, 1989, and updated successor revised manuals.
(p) "Suspension" means the health care organization's authority to enter into new, renewed, or amended contracts with claims administrators has been suspended by the administrative director for a specific period of time.
(q) "Utilization review" or "Utilization Management" is the system used to manage, assess, improve, or review patient care and decision-making through case by case assessments of the medical reasonableness or medical necessity of the frequency, duration, level and appropriateness of medical care and services, based upon professionally recognized standards of care. Utilization review may include, but is not limited to, prospective, concurrent, and retrospective review of a request for authorization of medical treatment.
Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 3300, 4061.5, 4600.5, 5400, 5401 and 5402, Labor Code.
s 9771. Applications for Certification.
(a) Any of the following entities may apply for certification as a health care organization:
(1) A disability insurer licensed by the Department of Insurance to transact health insurance or disability income insurance pursuant to Part 2 of Division 2 of the Insurance Code.
(2) Any workers compensation health care provider organization.
(b) An applicant must meet all of the requirements set forth in this article in order to be certified as a health care organization by the administrative director. Applicants must initially submit to the administrative director, as part of the application, a plan which will provide a clear and concise description of how occupational medical and health care services are to be provided and how each of the requirements in this article are met, and, where specified, in the manner required under each section. HCOs must include all documentation necessary to demonstrate that they meet the requirements for certification.
(c) Health care service plans must provide written certification that at the time of application the applicant is not in violation of any provision of law or rules or orders of the Director of the Department of Managed Health Care, and that there are no outstanding orders, undertakings, or deficiency letters which involve the applicant. Disability insurers must provide written certification that at the time of application they are in good standing with the Department of Insurance. The requirement of this subdivision may be satisfied by verified statement under penalty of perjury by the president or managing officer of an applicant that the applicant meets the requirements of this subdivision, subject to verification by the administrative director.
(d) An applicant who is in compliance with requirements for certification by the Department of Insurance may submit copies of any relevant exhibits, sections or other documents submitted as part of the primary certification application to meet any of the requirements of this article, provided that the applicant (1) verifies that the Department of Insurance has fully reviewed and approved the submitted information, (2) provides a concise narrative identifying any manner in which HCO services will be provided differently from those provided under the primary certification, and (3) provides a concise description for each requirement of this article, specifying how occupational medical and health care services or other services specifically and exclusively required by this article will be met.
(e) Applications must be in writing in the form and manner prescribed by the administrative director, and must be submitted on or after January 1, 1994. The original plus one copy of the application shall be submitted together with a fee as specified in subdivision (c). Each application shall provide, in addition to the plan specified in subdivision (b), the following information:
(1) The names of all directors and officers of the health care organization;
(2) The title and name of the person designated to be the day-to-day administrator of the health care organization.
(3) The title and name of the person designated to be the administrator of the financial affairs of the health care organization.
(4) The name, medical specialty, if any, board certification, if any, and any unrestricted licenses (including states where licensed), of the medical director.
(5) The name, address, and telephone number of a person designated to serve as a liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the HCO organization.
(6) A sample of each type of contract with participating providers, claims administrators, and insurers, and any entities specifically providing services required by this article; and a list of contractors for each type of contract. Copies of contracts shall be made available to the administrative director upon request. The Division will maintain as confidential information pertaining to provider rates and other financial information in accordance with Government Code Section 6254(d)(1).
(7) An organizational chart demonstrating the structural relationships between the medical director, fiscal or financial administrator, and executive officers and administrators.
(8) The identity of any worker's compensation insurer that controls or is controlled by the applicant, as defined by Section 1215 of the Insurance Code.
(f) Each application for certification must be accompanied by a non refundable fee of $20,000.
(g) In lieu of an application for certification, an entity licensed as a full service health care service plan under Section 1353 of the Health and Safety Code (a Knox-Keene Health Care Service Plan Act) and deemed to be an HCO pursuant to Labor Code Section 4600.5(c) shall submit to the administrative director:
(1) a concise description of how the health plan will satisfy the requirements of Labor Code Section 4600.5(c)(1 - 5) and Sections 9772 through 9778, inclusive, of these regulations. At the time the materials required by this subsection are submitted to the administrative director for review, the health plan shall pay a nonrefundable documentation processing and review fee of $10,000; and,
(2) written certification that the health plan is not in violation of any provisions of law or rules or orders of the Director of the Department of Managed Health Care, and that there are no outstanding orders, undertakings, or deficiency letters which involve the health plan. The requirements of this subdivision may be satisfied by verified statement under penalty of perjury by the president or managing officer of the health plan that the plan meets the requirements of this subdivision, subject to verification by the administrative director.
Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.
s 9771.1. Updating Applications.
(a) Every application submitted under Section 9771(e) shall be kept current to reflect accurately the actual operation of the HCO. An applicant or a certified HCO shall file an amendment to its application to show any change in any information contained in the application. Amendments include changes, deletions, additions and variations to the original application and its exhibits, including sample contracts. Amendments shall be filed as set forth in this section. However, the administrative director may approve an alternative form of submitting an amendment if it substantially accomplishes the purposes of this section.
(b) An original and one copy of an amendment shall be submitted to the administrative director as follows:
(1) Submit an Execution Page of the application, indicating it is an "Amendment to Pending Application" or "Amendment to Application of a Certified Organization";
(2) Furnish only those pages of the application and/or those exhibits which are changed by the amendment.
(3) If a page of the application is amended, complete all items on that page and "redline" or otherwise clearly designated the changed item. At the lower left-hand corner of each page, type "Rev. [date]", giving the effective date of the amendment.
(4) If an exhibit is being amended:
(A) Furnish the complete exhibit as amended, bearing the same number as the original exhibit, with the changed portions of the exhibit "redlined" or otherwise clearly designated, or
(B) Furnish the pages of the exhibit which are amended, each page to be marked with the exhibit number and the page number of the exhibit, and with the changed portions "redlined" or otherwise clearly designated. At the lower left-hand corner of each page, type "Rev. [date]", giving the effective date of the amendment. If this method of amendment is employed, the applicant shall refile the entire exhibit as amended whenever more than 10 percent if its pages have been amended.
(2) In the event that it is impossible to submit a proposed material change in the application 30 days before the change is implemented, the applicant shall submit the change as soon as the applicant becomes aware that a change is required. If, in the opinion of the administrative director, the change or proposed changed raises a question as to the ability of a certified HCO to meet the requirements of this article, the administrative director may, within 30 days of receiving notice of the change inform the HCO of the question. When the administrative director informs the HCO that a question exists, the HCO may not implement the proposed change, or shall cease implementing the change. The HCO may submit whatever materials it deems appropriate to justify the amendment and may meet with the administrative director or staff to discuss the question. Within 30 days after informing the HCO of the question, the administrative director shall inform the HCO whether the amendment is approved or disapproved.
(d) Amendments making non-material changes shall be filed quarterly on dates specified by the administrative director. However, a list of providers need be amended only when 10 percent or more of the names contained in the list for a service area have been changed or when the sole or principal provider for a particular health care service in a service area is added or deleted. When amended, the complete list (or the list for the service area) shall be furnished following the instructions for the particular item, with each added "redlined" or otherwise clearly designated and the names of persons deleted from the list shown at the end under the heading "deletions."
(e) Review of amendments submitted under section 9771.1, except quarterly updates under section 9771.1(e)(2), will be charged based on the actual cost for performing the review. The amount shall include the actual salaries or compensation paid to the persons reviewing amendment; the expenses incurred in the course thereof, and overhead costs in connection therewith as fixed by the Administrative Director. Overhead costs shall be based on the total expenditure for operating expenses and equipment, except travel, of the managed care unit of the Division of Workers' Compensation for the previous fiscal year. The invoice will be sent upon the completion of the review and shall be paid within 30 calendar days.
Note: Authority: Sections 133, 4600.5, 4600.7, 5307.3, Labor Code. Reference: Sections 4600.3, 4600.5, Labor Code.
s 9771.2. Information to Be Furnished as it Becomes Available.
(a) If an HCO, or any person listed in section 9771(e)(8), is named as a defendant in a lawsuit that is materially related to the provision of medical treatment under Labor Code section 4600, the HCO shall inform the administrative director within 5 days of the day it becomes aware the suit is filed and shall provide a copy of the complaint.
(b)(1) If a certified HCO is a health care services plan and if the Director of the Department of Managed Health Care begins proceedings against the plan under Articles 7 or 8 of the Knox-Keene Health Care Service Plan Act of 1975, the certified HCO shall inform the administrative director within 5 days of the day it becomes aware of the proceedings. The requirements of this subdivision shall also apply to an HMO deemed an HCO pursuant to Labor Code Section 4600.5(c) while the administrative director is reviewing the documentation required by Section 9771 subdivisions (g)(1) and (2) prior to issuing the HMO its certification.
(2) If an applicant or a certified HCO is a disability insurer and if the Commissioner of Insurance begins proceedings against the insurer under Insurance Code section 704 or an examination under section 730, the applicant or certified HCO shall inform the administrative director within 5 days of the day it becomes aware of the proceedings or examination.
(c) A change in the information required by Section 9771(e) (1), (2), (3), (4), (5), and (8) shall be submitted within 5 days of the change.
(d) If an applicant or an affiliate of an applicant enters a contract whereby the applicant is to be purchased by or otherwise come under the control of another entity, the applicant shall notify the administrative director within 5 days of entry into the contract.
Note: Authority: Sections 133, 4600.5, 5307.3, Labor Code. Reference: Sections 4600.3, 4600.5, Labor Code.
s 9771.6. Application of Regulations Concerning Workers' Compensation Health Care Provider Organizations.
Sections 9771.6 through 9771.83 apply only to workers' compensation health care organizations as defined by Section 9771.60(m).
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
s 9771.60. Further Definitions.
The following definitions apply to the interpretation of these rules and the Act:
(a) "Act" means Sections 4600.3, 4600.5 and 4600.6 of the Code
(b) "Advertisement" includes the disclosure form required pursuant to Section 4600.6(e) of the Code.
(c)(1) An "affiliate" of a person is a person controlled by, under common control with, or controlling such person.
(2) A person's relationship with another person is that of an "affiliated person" if such person is, as to such other person, a director, trustee or a member of its executive committee or other governing board or committee, or that of an officer or general partner, or holds any other position involving responsibility and authority similar to that of a principal officer or general partner; or who is the holder of 5 percent or more of its outstanding equity securities; or who has any such relationship with an affiliate of such person. An affiliate is also an affiliated person.
(d) The term "control" (including the terms "controlling," "controlled by" and "under common control with") means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting shares, debt, by contract, or otherwise.
(e) The term "certified" or "audited," when used in regard to financial statements, means examined and reported upon with an opinion expressed by an independent public or certified public accountant.
(f) "Code" means the California Labor Code.
(g) "Administrative Director" means the Administrative Director of the Division of Workers' Compensation.
(h) "Facility" means (1) any premises owned, leased, used or operated directly or indirectly by or for the benefit of an organization or any affiliate thereof, and (2) any premises maintained by a provider to provide services on behalf of an organization.
(i) "Material": A factor is "material" with respect to a matter if it is one to which a reasonable person would attach importance in determining the action to be taken upon the matter.
(j) "Principal creditor" means (1) a person who has loaned funds to another for the operation of such other person's business, and (2) a person who has, directly or indirectly, 20 percent or more of the outstanding debts of a person.
(k) "Principal officer" means a president, vice-president, secretary, treasurer or chairman of the board of a corporation, a sole proprietor, the managing general partner of a partnership, or a person having similar responsibilities or functions.
(l) The term "generally accepted accounting principles," when used in regard to financial statements, assets, liabilities and other accounting items, means generally accepted accounting principles as used by business enterprises organized for profit. Accordingly, Financial Accounting Standards Board statements, Accounting Principles Board opinions, accounting research bulletins and other authoritative pronouncements of the accounting profession should be applied in determining generally accepted accounting principles unless such statements, opinions, bulletins and pronouncements are inapplicable. Section 510.05 of the AICPA Professional Standards, in and of itself, shall not be sufficient reason for determining inapplicability of statements, opinions, bulletins and pronouncements.
(m) Workers' compensation health care provider organization" or "organization" means an entity authorized by the Administrative Director to be a health care organization pursuant to Section 4600.5(e) and 4600.6, or an entity applying for such authorization.
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
s 9771.61. Prohibition of Bonuses or Gratuities in Solicitations.
No person subject to the provisions of the Act shall offer or otherwise distribute any bonus or gratuity to a potential self-insured employer, group of self-insured employers, or insurer of an employer for the purpose of inducing enrollment or to an existing self-insured employer, group of self-insured employers, or insurer of an employer for the purpose of inducing the continuation of enrollment.
Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.
s 9771.62. Application for Authorization as a Workers' Compensation Health Care Provider Organization.
(a) An application for authorization as a workers' compensation health care provider organization shall be filed in the form specified in subsection (c) and contain the information specified in this section.
(b) Applications will be processed in the order in which they are filed; provided however, that applications under Section 4600.5(f)(2) shall have priority.
(c) Application Form (WHWCPO-1).
DIVISION OF WORKERS' COMPENSATION
SUPPLEMENTARY APPLICATION
UNDER LABOR CODE SECTION 4600.6.
Date of Application:
WORKERS' COMPENSATION HEALTH CARE PROVIDER
ORGANIZATION AUTHORIZATION APPLICATION
LABOR CODE SECTION 4600.6 (EXECUTION PAGE)
Identification of Organization.
Name of Applicant.
a. Legal name: __________
b. Please list all fictitious names you intend to use
A. Type of Filing: Indicate the type of filing by checking and completing the appropriate items:
1. ( ) Original application for organization authorization.
2. ( ) Amendment #___ to a pending application dated ______ for organization authorization. (Complete Item A-5 below.)
3. ( ) Notice of a proposed material modification (Complete Item A-5 below.)
4. ( ) Amendment filed by an organization because of a change in the information contained in the original application. (Complete Item A-5 below.)
5. Item numbers being amended
Exhibit numbers being amended
B. Other Agencies.
1. If applicant has made or intends to make any filing relating to its plan of operation to any other state or federal agency, check here ___, and attach Exhibit B-1 identifying each such agency, and the nature, purpose and (projected) date of each such filing.
Additional Exhibits: An original application for organization authorization must include the completed form specified in this subsection and the exhibits required.
C. Summary of Information in Application.
1. Summary Description of Organization and Operation. Provide as Exhibit C-1 a summary description of the organization and operation of applicant's business as a workers' compensation health care provider organization, covering the highlights and essential features of the information provided in response to the other portions of this application which is essential or desirable to an effective overview of the applicant's workers' compensation health care business, including a summary of the applicant's experience in the provision of workers' compensation health care. (continued)