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(continued)
(5) Review of the overall performance of the organization in providing workers' compensation health care, by consideration of the following:
(A) The numbers and qualifications of health professional and other personnel;
(B) The provision of, incentives for, and participation in, continuing education for health personnel and the provision for access to current medical literature;
(C) The adequacy of all physical facilities, including lighting, cleanliness, maintenance, equipment, furnishings, and convenience to employees, organization personnel and visitors;

(D) The practice of health professionals and allied personnel in a functionally integrated manner, including the extent of shared responsibility for patient care and coordinated use of equipment, medical records and other facilities and services;
(E) The appropriate functioning of health professionals and other health personnel, including specialists, consultants and referrals;
(F) Nursing practices, including reasonable supervision;
(G) Written nondiscriminatory personnel practices which attract and retain qualified health professionals and other personnel;
(H) The adequacy and utilization of pathology and other laboratory facilities, including the quality, efficiency and appropriateness of laboratory procedures and records and quality control procedures;
(I) X-ray and radiological services, including staffing, utilization, equipment, and the promptness of interpretation of X- ray films by a qualified provider;

(J) The handling and adequacy of medical record systems, including filing procedures, provisions for maintenance of confidentiality, the efficiency of procedures for retrieval and transmittal, and the utilization of sampling techniques for medical records audits and quality of care review;
(K) The adequacy, including convenience and readiness of availability to employees, of all provided health care;
(L) How the organization is organized and its mechanisms for furnishing workers' compensation health care, including the supervision of health professionals and other personnel;
(M) The extent to which individual medical decisions by qualified medical personnel are unduly constrained by fiscal or administrative personnel, policies or considerations;
(N) The adequacy of staffing, including medical specialties.
(6) Review of the overall performance of the organization in meeting the health needs of employees.

(A) Accessibility of facilities and workers' compensation health care, based upon location of facilities, hours of operation, waiting periods for health care and appointments, the availability of parking and transportation;
(B) Continuity of health care, including the ability of employees to select a primary treating physician, staffing in medical specialties or arrangements therefor; the referral system (including instructions, monitoring and follow-up); the maintenance and ready availability of medical records; and the availability of health care education to employees;
(C) The grievance procedure required by Section 4600.6(j) of the Code, including the availability to employees of grievance procedure information, the time required for and the adequacy of the response to grievances and the utilization of grievance information by the organization's management.
(7) In considering the above and in pursuit of the survey objectives, the survey team may perform any or all of the following procedures:
(A) Private interviews and group conferences with employees, physicians and other health care professionals and providers, and members of its administrative staff including, but not limited to, persons in principal management positions.
(B) Examination of any records, books, reports and papers of the organization and of any management company, provider or subcontractor providing workers' compensation health care or other services to the organization including, but not limited to, the minutes of medical staff meetings, peer review, and quality of care review records, duty rosters of medical personnel, surgical logs, appointment records, the written procedures for the internal operation of the organization, and contracts and correspondence with employees and with providers of workers' compensation health care and of other services to the organization, and such additional documentation the Administrative Director may specifically direct the surveyors to examine.
(C) Physical examination of facilities, including equipment.
(D) Investigation of grievances or complaints from employees, or from the general public.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.77. Medical Survey: Report of Correction of Deficiencies.
Prior to or immediately upon the expiration of the 30-day period following notice to an organization of a deficiency as provided in subdivision (8) of Section 4600.6(o) of the Code, the organization shall file a written statement with the Administrative Director identifying the deficiency and describing the action taken to correct the deficiency and the results of such action. The report shall be signed by a principal officer of the organization.
Where such deficiencies reasonably may be adjudged to require long-term corrective action or to be of a nature which reasonably may be expected to require a period longer than 30 days to remedy, evidence that the organization has initiated remedial action and is on the way to achieving acceptable levels of compliance may be submitted for review by the Administrative Director.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.78. Removal of Books and Records from State.
The books and records of an organization, management company, solicitor firm, and any provider or subcontractor providing workers' compensation health care or other services to an organization, management company, or solicitor firm shall not be removed from this state without the prior written consent of the Administrative Director.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.79. Examination Procedure.
Regular and additional or nonroutine examinations conducted by the Administrative Director pursuant to Section 4600.6(q) of the Code will ordinarily be commenced on an unannounced basis. To the extent feasible, deficiencies noted will be called to the attention of the responsible officers of the company under examination during the course of the examination, and in that event the company should take the corrective action indicated. When deemed appropriate, the company will be advised by letter of the deficiencies noted upon the examination. If the deficiency letter requires a report from the organization, such report must be furnished within 15 days or such additional time as may be allowed.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.80. Additional or Nonroutine Examinations and Surveys.
(a) An examination or survey is additional or nonroutine for good cause for the purposes of Section 4600.6(q) of the Code when the reason for such examination or survey is any of the following:
(1) The organization's noncompliance with written instructions from the Administrative Director;
(2) The organization has violated, or the Administrative Director has reason to believe that the organization has violated, any of the provisions of Sections 4600.3, 4600.5, or 4600.6 of the Code or regulations referring to those sections.
(3) The organization has committed, or the Administrative Director has reason to believe that the organization has committed, any of the acts or omissions enumerated in Section 4600.5(k) of the Code.
(4) The Administrative Director deems such additional or nonroutine examination or survey necessary to verify representations made to the Administrative Director by an organization in response to a deficiency letter.
(b) Each situation giving rise to an additional or nonroutine examination or survey shall be evaluated on a case-by-case basis as to the seriousness of the violation, or lack of timely or adequate response by the organization to the Administrative Director's request to correct the violation. The organization shall be notified in writing of the provisions of the Act or regulations which have been, or may have been, violated and which therefore caused such additional or nonroutine examination or survey to be performed. The expense of such examinations and surveys shall be charged to the organization being examined or surveyed in accordance with Section 4600.6(q) of the Code.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.81. Financial Statements.
(a) Whenever pursuant to these rules or pursuant to an order or request of the Administrative Director under the Code a financial statement or other report is required to be audited or be accompanied by the opinion of a certified public accountant, such accountant shall be independent of the licensee, determined in accordance with Section 602.02 of Financial Reporting Release No. 1 issued by the Securities and Exchange Commission (Securities Act Release 6395, April 15, 1982).
(b) The financial statements shall be audited by an independent accountant in accordance with Rule 9771.60(e).
(c) Except as provided in subsection (d), financial statements of an organization required pursuant to these rules must be on a combining basis with an affiliate, if the organization or such affiliate is substantially dependent upon the other for the provision of workers' compensation health care, management or other services. An affiliate will normally be required to be combined, regardless of its form of organization, if the following conditions exist:
(1) The affiliate controls, is controlled by, or is under common control with, the organization, either directly or indirectly (see subsections (c) and (d) of Rule 9771.60), and
(2) The organization or the affiliate is substantially dependent, either directly or indirectly, upon the other for services or revenue.
(d) Upon written request of an organization, the Administrative Director may waive the requirement that an affiliate be combined in financial statements required pursuant to these rules. Normally, a waiver will be granted only when

(1) the affiliate is not directly engaged in the delivery of workers' compensation health care or
(2) the affiliate is operating under an authority granted by a governmental agency pursuant to which the affiliate is required to submit periodic financial reports in a form prescribed by such governmental agency that cannot practicably be reformatted into the form prescribed by these rules (such as an insurance company).
(e) When combined financial statements are required by this section, the independent accountant's report or opinion must cover all the entities included in the combined financial statements. If the accountant's report or opinion makes reference to the fact that a part of the examination was performed by another auditor, the organization shall also file the individual financial statements and report or opinion issued by the other auditor.
(f) Organizations which have subsidiaries that are required to be consolidated under generally accepted accounting principles must present either
(1) consolidating financial statements, or

(2) consolidating schedules for the balance sheet and statement of operations, which in either case must show the organization separate from the other entities included in the consolidated balances.
(g) This section shall not apply to an organization which is a public entity or political subdivision.
(h) All filings of financial statements required pursuant to these rules must include an original and one copy.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.82. Books and Records.
(a) Each organization, solicitor firm, and solicitor shall keep and maintain their books of account and other records on a current basis.
(b) Each organization shall make or cause to be made and retain books and records which accurately reflect:
(1) The names and last known addresses of all employees eligible to receive workers' compensation health care, and all contracting self-insured employers, groups of self-insured employers and insurers of employers.
(2) All contracts required to be submitted to the Administrative Director and all other contracts entered into by the organization.
(3) All requests made to the organization for payment of moneys for workers' compensation health care, the date of such requests, and the dispositions thereof.
(4) A current list of the names and addresses of all individuals employed by the organization as solicitors.
(5) A current list of the names and addresses of all solicitor firms with which the organization contracts.
(6) A current list of the names and addresses of all of the organization's officers, directors, principal shareholders, general managers, and other principals.
(7) The amount of any commissions paid to persons who obtain self-insured employers, groups of self-insured employers, and insurers of employers for workers' compensation health care provider organizations, and the manner in which said commissions are determined.
(c) Each solicitor firm shall make and retain books and records which include a current list of the names and addresses of its partners, if any, and all of its employees who make act as solicitors.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9771.83. Retention of Books and Records.
Every organization and solicitor firm shall preserve for a period of not less than five years, the last two years of which shall be in an easily accessible place at the offices of the organization or solicitor firm, the books of account and other records required under the provisions, and for the purposes, of the Act. After such books and records have been preserved for two years, they may be warehoused or stored, or microfilmed, subject to their availability to the Administrative Director within not more than 5 days after request therefore.


Note: Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.





s 9772. General Standards.
(a) HCOs must demonstrate that they meet the following requirements:
(1) All facilities located in this state including, but not limited to, clinics, hospitals, laboratories, and skilled nursing facilities to be utilized by the HCO for the delivery of occupational medical and health care services or other services specifically required by this article shall be licensed by the State Department of Health Services, if such licensure is required by law, and shall meet any other relevant certification requirements. Facilities not located in this state shall conform to all licensing and other requirements of the jurisdiction in which they are located.
(2) All personnel employed by or under contract to the HCO shall be licensed or certified by their respective board or agency, where such licensure or certification is required by law.
(3) All equipment required to be licensed or registered by law shall be so licensed or registered and the operating personnel for such equipment shall be licensed or certified as required by law.
(4) The HCO shall provide continuity of care and timely referral of patients to other providers in a manner consistent with professionally recognized standards of care.
(5) All services shall be available and accessible at reasonable times to all HCO enrollees.
(6) The HCO may employ and utilize allied health personnel for the furnishing of occupational health services to the extent permitted by law and provided such use is consistent with professionally recognized standards of care; however, any course of treatment beyond first aid, as defined in subdivision (c) of Section 14311, shall provide for at least one face to face visit with a primary treating physician.
(7) The HCO shall have the organizational, financial, and administrative capacity to provide services to employers, claims administrators, and HCO enrollees. The HCO shall be able to demonstrate to the Division that medical decisions are rendered by qualified providers unhindered by fiscal and administrative management, and that such decisions adhere to professionally recognized standards of care.
Any applicant that is owned in whole or in part or controlled by a workers' compensation insurer or self-insured employer shall, in addition to the requirements set forth above, further demonstrate that the organization's claims function shall have no influence or control over medical decision-making. The applicant shall further demonstrate that the clear authority of its Medical Director over all medical decisions is reflected both in its organizational chart and any internal procedure manual or other internal description of HCO operations.
(8) All contracts with claims administrators, employers, providers and other persons or entities furnishing services specifically required by this article shall be consistent with the requirements of this article and Division 4 of the Labor Code.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Section 4600.5, Labor Code.





s 9773. Treatment Standards.
(a) HCOs shall provide all HCO enrollees with access to all medical, surgical, chiropractic, and hospital treatment which is reasonably required to cure or relieve the effects of an injury in accordance with Section 4600 of the Labor Code. This treatment must be provided without payment of any co-payment, deductible, or premium share by an HCO enrollee. HCOs must provide a description of the method for providing treatment required under the code, including a list of its physical facilities. The description must include the occupational health care delivery capabilities of the HCO, including the number of primary treating physicians and specialists, the number and types of licensed or state-certified health care support staff, the number of hospital beds, and the arrangements and the methods by which occupational health care services will be provided, which shall include the following:
(1) Provider services, including consultation and referral. HCOs must identify the total number of full time equivalent physicians and providers of each different specialty type available to provide treatment for work injuries or illnesses on a regular basis.
(2) Inpatient hospital services, which shall include acute hospital services, general nursing care, use of operating room and related facilities, intensive care unit and services, diagnostic laboratory and x-ray services, special duty nursing as medically necessary, physical therapy, respiratory therapy, administration of blood and blood products, and other diagnostic, therapeutic and rehabilitative services as medically reasonable or medically necessary, and coordinated discharge planning including planning of such continuing care as may be necessary, both medically and as a means of preventing possible rehospitalization.
(3) Ambulatory care services, (including outpatient hospital services) which shall include diagnostic and treatment services, physical therapy, speech therapy, occupational therapy services as appropriate, and those hospital services which can reasonably be provided on an ambulatory basis.
(4) Emergency services, including ambulance services and out-of-area coverage for emergency care.
(5) Diagnostic laboratory services, diagnostic and therapeutic radiological services, and other diagnostic services.
(6) Home health service, which shall include, where medically appropriate, health services provided at the home of an HCO enrollee as provided or prescribed by a physician or osteopath licensed to practice in California. Such home health services shall be provided in the home, including nursing care, performed by a registered nurse, public health nurse, licensed vocational nurse or licensed home health aide.
(b) HCOs shall provide a description of the times, places and manner of providing services under the HCO, including a description of the geographical service area. The geographical service area shall be designated by a list of the postal zip codes in the service area, and a map indicating the type and number of facilities within the service area. The following requirements must be met unless the HCO shows that a lack of a type of provider exists in an area and that the minimum number is not available:
(1) At least one full-time equivalent primary treating physician shall be available within the geographical proximity specified in paragraph (2) for every 1,200 expected injuries or illnesses. The HCO shall provide information on expected case-load and the methodology, data and assumptions used in the calculations.
(2) HCO enrollees must have a residence or workplace within 30 minutes or 15 miles of (i) a primary treating physician or (ii) a contracting or HCO-operating hospital, or if separate from such hospital, a contracting or HCO-operated provider of all emergency health care services. Enrollees must have a residence or workplace within 60 minutes or 30 miles of all other occupational health services listed in subdivision (a).
(3) The HCO must provide a description of how access to any of the basic health services listed in subdivision (a) will be provided to HCO enrollees who reside outside the HCO's geographical service area such that the requirements of this subdivision are met.

(4) Initial treatment for non-emergency services must be made available by an HCO within 24 hours of the HCO's receipt of a request for treatment.
(5) The HCO must describe how treatment is initiated and how an HCO enrollee is assigned a primary treating physician.
(6) Enrollees shall be entitled to at least one change of physician for an injury. The HCO shall provide the employee, within five days of a request by an HCO enrollee, with a choice of any other available participating provider in the appropriate specialty.
(7) HCO enrollees shall be provided with a second opinion, upon request, from a participating provider.
(8) The HCO must describe how it will make available interpreter's services, as required, for the treatment or evaluation of patients.
(9) The HCO must describe how the HCO will treat an injury or illness pending a claims administrator's decision concerning liability for treatment.

(10) HCOs must maintain and make available or insure that their contracted medical providers maintain and make available medical records to treating or evaluating physicians in a timely manner.
(c) The HCO shall describe its process for coordinating all aspects of medical treatment, including the coordination and monitoring of referrals to consultants, therapeutic or diagnostic facilities, reporting of treatment, being responsive to the HCO patient's request for change of physician or physician referrals as may be required by this article, and for ensuring timeliness of referrals and timely response to the primary treating physician.
(d) The HCO must include at least one full-time equivalent board-certified occupational medicine employed or contracting physician to provide expertise on workplace health and safety issues and prevention and treatment of occupational injuries and illnesses. The HCO shall describe its ongoing educational program to ensure that all primary treating physicians receive education, training or experience in occupational medicine and workers compensation, including but not limited to, the following:
(1) The regulatory requirements for primary treating physicians in workers' compensation;

(2) Familiarity with workplace hazards, causes of workplace injury, work restrictions, and vocational rehabilitation;
(3) The requirements of medical-legal reports in workers compensation,


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 3209.3, 4600 and 4600.5, Labor Code.





s 9773.1. Referrals to Chiropractors.
HCOs shall maintain guidelines for chiropractor care in accordance with paragraph (2) of subdivision (1) of Section 4600.5 of the Labor Code. The HCO must include a description of the HCO'sguidelines and utilization review process for chiropractic care, including the HCO's definition of "neuromusculoskeletal condition", and the procedure whereby enrollees may be referred to chiropractors in accordance with the HCO's guidelines.

Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Section 3209.3, 4600 and 4600.5, Labor Code.





s 9774. Quality of Care.
(a) An HCO must include a written program designed to ensure a level of care for occupational injuries and illnesses which meets professionally recognized standards of care. The program must be designed and directed by providers to document that the quality of care provided is reviewed, that problems are identified, that effective action is taken to improve care where deficiencies are identified, that follow-up measures are planned where indicated, and that all of the requirements of this division are met. The plans must describe the goals and objectives of the program and organizational arrangements, including staffing, the methodology for on-going monitoring and evaluation of health services, the scope of the program, and required levels of activity. Quality of care problems must be identified and corrected. The program must demonstrate that the HCO's utilization review activities are designed to improve the quality of care provided.
The HCO shall describe and implement a program, including the following:
(1) A description of the process whereby the medical reasonableness or medical necessity of requests for authorization are reviewed and decisions on such requests are made by the HCO. The description shall include the specific criteria utilized in the review and throughout the decision-making process, including treatment protocols or standards in any software, database, or other resource used in the process. Treatment protocols must be consistent with any guidelines adopted pursuant to paragraph (8) of subdivision (e) of Section 139 of the Labor Code.
(2) A description of the qualifications of the personnel involved in reviewing and making decisions concerning requests for authorization, including the professional qualifications of the personnel, and the manner in which such personnel are involved in the review process. Medical decisions must be rendered by physicians with licenses unrestricted by their licensing board.
(3) A description of manual and automated data storage and retrieval systems for medical and utilization review; and the types of data analyses, reports, and manner in which results are communicated to providers.
(b) The HCO's quality assurance committee shall meet on at least a quarterly basis or more frequently if problems have been identified, to oversee its quality assurance program responsibilities. Reports to the HCO's governing body shall be sufficiently detailed to include findings and actions taken as a result of the quality assurance program and to identify those internal or contracting provider components which the quality assurance program had identified as presenting significant or chronic quality of care issues.
(c) The HCO is responsible for establishing a quality assurance program to monitor and evaluate the care provided by each contracting provider group or facility. Medical groups or other provider entities may have active quality assurance programs which the HCO may use. However, the HCO must retain responsibility for reviewing the overall quality of care delivered to HCO enrollees. To the extent that the HCO's quality assurance responsibilities are delegated within the HCO or to a contracting provider or facility, the HCO shall provide evidence of an oversight mechanism for ensuring that delegated quality assurance functions are adequately performed.
(d) Physicians must be an integral part of the quality assurance program. Design and implementation of the quality assurance program shall be supervised by designated physicians. Physician participation in quali ty assurance activity must be adequate to monitor the full scope of clinical services rendered, resolve problems and ensure that corrective action is taken when indicated. Specialist providers must also be involved in peer review of like specialties.
(e) The HCO may delegate inpatient quality assurance functions to hospitals, however in such case a HCO must fully describe and monitor that hospital's quality assurance program.
(f) The HCO must insure that all comprehensive medical-legal reports are prepared in an objective, fair, and unbiased manner, and that such reports are prepared in accordance with Section 4628 of the Labor Code, any applicable procedures promulgated under Section 139.2 of the Labor Code, and the requirements of Section 10606. The HCO or physician shall retain, for no less than three years, copies of all comprehensive medical evaluation reports which are prepared by any of its physicians to determine an employee's eligibility for compensation. These reports shall be made available to the administrative director upon request. The administrative director may review such reports as he or she deems necessary to insure compliance with this subdivision, and the results of this review may be used to deny recertification if it is determined that a significant number of an HCO's reports show bias or are legally inadequate.
(g) The HCO must describe how it will assess its activities as required by Sections 9776 and 9776.1 and the HCO's system for assuring data quality.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.5 and 4628, Labor Code.





s 9775. Grievance and Dispute Resolution Procedure.
(a) HCOs must maintain a grievance procedure under which HCO enrollees or participating providers may submit grievances to the HCO. Each HCO must include a system for resolving disputes which shall include HCO enrollee disputes with a provider and a provider's dispute with the HCO. The HCO must provide that either an HCO enrollee or a provider shall be able to initiate a grievance. Each HCO must provide reasonable procedures which insure adequate consideration of enrollee and provider grievances or disputes and which provide prompt rectification when appropriate.
(b) Compliant forms and a copy of the grievance procedure shall be readily available through each provider facility and through the claims administrator, and shall be furnished promptly upon receipt of a verbal or written request.
(c) If a grievance or dispute concerns the medical reasonableness or medical necessity of treatment recommended by a provider, the HCO must provide for an expedited procedure for review of the grievance or dispute by physicians or qualified professional providers not previously involved in the grievance or dispute and who possess the specialty which is appropriate to the medical nature of the disputed treatment. Under no circumstance may the appeal decision be made by a registered nurse. The HCO must issue a written decision as to the grievance or dispute within 30 days unless the HCO enrollee's medical condition requires a more expedited decision.
(d) Each HCO shall inform providers and HCO enrollees, or their representatives, that they may file a written complaint to the administrative director
(e) The HCO shall annually provide to the administrative director a summary of written grievances received concerning the provision of occupational health services, including the number of total grievances received and processed. Records of all written grievances concerning the provision of occupational health services, including the name of the grievant, the nature of the complaint or grievance, and the manner in which the grievance was resolved or referred for further action, shall be kept by the HCO for a period of not less than 3 years and shall be made available by the HCO to the administrative director as he or she deems necessary.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.





s 9776. Workplace Safety and Health.
(a) The HCO must maintain the capability to work cooperatively and in conjunction with claims administrators, employers, and employees to promote workplace health and safety and to detect workplace exposures and hazards, including:
(1) education of employees and employers on health and medical aspects of workplace health and safety issues;

(2) consultation on employee medical screening for early detection of occupational disease, and assessment of workplace risk factors.
(b) An HCO shall include in contracts with claims administrators a provision which enables the HCO to obtain upon request information to allow appropriate provider decision-making regarding diagnoses, patient medical restrictions, early disease detection, or return-to-work, which may include:
(1) the employer's written Injury and Illness Prevention Plan, including the name and title of individual responsible for implementing the plan.
(2) information concerning exposure levels for specified materials, and information, including Material Safety Data Sheets, concerning health, safety, and ergonomic risk factors in the workplace.
(3) the name and title of the individual responsible for loss control services for each employer.
(c) The HCO shall have in place a program for prompt reporting,to the employer or insurer loss control program and to the employer's designee responsible for the Injury and Illness Prevention Plan, of the following occupational injuries and illnesses: occupational asthma; cumulative trauma disorders of the upper extremities; lead poisoning; amputations (excluding amputations of the distal phalanges); noise-induced hearing loss; pesticide illness; electrocutions; asphyxiation; and burns and falls from heights requiring hospitalization.
(d) The HCO shall annually report to the insurer loss control program or to the employer's designee responsible for the Injury and Illness Prevention Plan as designated in the contract between the HCO and the claims administrator, aggregate data on injuries and illnesses.





s 9776.1. Return to Work Coordination.
An HCO shall maintain a return to work program in conjunction with the employer and claims administrator to facilitate and coordinate returning injured workers to the workplace, to assess the feasibility and availability of modified work or modified duty, and to minimize risk of employee exposure after return to work to risk factors which may aggravate or cause recurrence of injury. The duties of the HCO shall be specified in the contract between the HCO and the claims administrator.





s 9777. Patient Assistance and Notification.
(a) The HCO shall inform HCO enrollees upon enrollment in the plan and annually thereafter of the details of their coverage, and their rights and options under the HCO including: (1) how HCO enrollees are informed of the procedure for processing and resolving grievances, including the location(s) and telephone number where grievances may be submitted; and (2) how HCO enrollees are informed of their right to file a complaint with the administrative director in accordance with subdivision (d) of Section 9775.
(b) The HCO shall provide patient education specifically designed for injured workers with work-related injuries or illnesses.
(c) HCO enrollees must be able to receive information on a 24-hour basis regarding the availability of necessary medical services available within the HCO. The information may be provided through recorded telephone message after normal working hours. It must include information on how the enrollee can obtain emergency services or other urgently needed care and how the employee can access an evaluation within 24 hours of the injury as required under paragraph 4 of subdivision (b) of section 9773.
(d) Informational materials must be in a form understandable to all enrollees and available in Spanish. HCOs must provide in their application a description of how the information specified in subdivisions (a) through (c) will be provided to HCO enrollees. A copy of the informational material provided to HCO enrollees, including the text of phone messages, shall be made available to the administrative director upon request.
(e) The HCO shall provide for periodic evaluation of the HCO by enrollees. The HCO must provide a survey to HCO enrollees and patients, which shall be in the form and manner prescribed by the administrative director. The HCO must describe its method for incorporating the results of the survey in its quality assurance program. The completed forms and any data extracted from such forms shall be made available to the administrative director upon request.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.





s 9778. Evaluation.
(a) The HCO must include a timely and accurate method to report to the administrative director the following information, in a standardized format to be prescribed by the administrative director:
(1) Cost of services under the plan, specific to particular industries and occupations, diagnoses, and procedures.
(2) Aggregated information on the number of HCO enrollees and their age, sex, geographical distribution, occupation, and SIC, by federal employer identification number.
(b) The HCO shall provide the following information on each injured enrollee.
i. For HCO enrollee claims opened in the calendar year:
(1) Patient's Employer's Federal Identification Number and SIC code.
(2) Injured enrollee name, date of birth, gender, social security number, and occupation.
(3) Date of injury.
(4) Diagnosis (ICD-9).
ii. For HCO enrollee claims closed during a calendar year, the following information linked with enrollee name, date of birth, and social security number:
(5) Medical Treatment, including dates of surgery and hospitalization.

(6) Date injured HCO enrollee released to return to work by the primary treating physician.
(7) Date injured HCO enrollee actually returned to work (not "released to work").
(8) HCO enrollee's job status at time of return to work (full or modified duty, or job different from pre-injury job), and employee's job status, including no longer employed, at time of close of claim.
(9) Permanent Disability rating.
(10) Whether injured HCO enrollee was represented by an attorney at any time through the claims process.
(c) Effective March 1, 2000, data elements required pursuant to paragraph (b) may instead be provided to the administrative director directly by the claims administrator in the format specified in Article 1.1 (commencing with section 9700), provided that:

(1) The claims administrator provides the data for all injured HCO enrollees for whom it contracts for medical care; and
(2) The HCO provides to the administrative director all information required by this section which is not provided by the claims administrator.
Information on claims opened and closed in the previous calendar year shall be made available by the HCO to the administrative director, in a form and manner to be prescribed by the administrative director, annually, on March 1, commencing with March 1, 1995.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.





s 9779. Certification.
(a) Once an applicant has completed an application and submitted a fee in accordance with Section 9771 and has demonstrated to the administrative director that its organization has met all of the criteria for certification, the administrative director will certify the organization as an HCO for a period of three years, unless earlier revoked or suspended.
(b) Once the Administrative Director has determined that 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) has complied with the requirements of Section 9771 subsections (g)(1) and (2) the administrative director shall certify the organization as an HCO, pursuant to Section 4600.5(c), for a period of three years unless earlier revoked or suspended.
(c) A certification shall state that a particular entity is certified as a health care organization to provide health care to injured employees for injuries and diseases and other services in accordance with the terms of the entity's application. The certification shall also state: (1) the geographic service area in which the health care organization is permitted to provide health care, (2) the maximum number of enrollees, (3) the name or names under which the health care organization is permitted to provide health care, (4) the date of expiration of the certification, and (5) any other conditions or limitations.
(d) The HCO will be recertified at the expiration of each subsequent three year period, provided it continues to meet the requirements of this article and timely pays a recertification fee of $10,000.

Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.5 and 4600.7, Labor Code.





s 9779.1. On-Site Surveys.
(a) The HCO must ensure that it will be available for and cooperate with on-site surveys as the administrative director deems necessary to insure compliance with this article, including during the initial certification process. The administrative director will coordinate on-site surveys with the Department of Managed Health Care to the extent feasible.
(b) The administrative director will notify the HCO of deficiencies found by the survey team. The administrative director will provide the HCO a reasonable time to correct the deficiencies. Failure on the part of the HCO to timely correct noted deficiencies may result in suspension or revocation of an HCO's certification in accordance with Section 9779.2.
(c) Reports of all surveys shall be open to public inspection, except that no survey shall be made public unless the HCO has had an opportunity to review the survey and file a statement in response within 30 days, to be attached to the report. Deficiencies shall not be made public if they are corrected within 30 days of the date that the HCO was notified.
(d) Non-routine audits will be charged based on the actual cost for performing the audit. The amount shall include the actual salaries or compensation paid to the persons making the audit, 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 audit and shall be paid within 30 calendar days.


Note: Authority cited: Sections 133, 4600.5, 4600.7, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600, 4600.5 and 4600.7, Labor Code.





s 9779.2. Suspension; Revocation; Hearing.
(a) Complaints pertaining to an HCO's violations of this article may be directed in writing to the administrative director. Upon receipt of a complaint, or in the course of monitoring the HCO's operations, the administrative director may investigate an alleged violation. The investigation may include, but not be limited to, a request for and review of pertinent HCO records, interviewing medical and administrative personnel, or an on-site medical survey. If the investigation reveals reasonable cause to belive that the HCO has violated a requirement of this article, the administrative director may initiate proceedings to suspend or revoke an HCO's certification.
(b) Certification of an HCO may be suspended or revoked if:
(1) Service under the HCO is not being provided according to the terms of the certified HCO.
(2) The HCO fails to meet the requirements of this article, the Labor Code, or other applicable law.
(3) False or misleading information is knowingly or repeatedly submitted by the HCO or a participating provider or the HCO knowingly or repeatedly fails to report information required by this article.
(4) The HCO 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 inured worker under California law.
(c) In the event an HCO or organization is formally notified of the administrative director's intention to revoke or suspend the HCO's certification, or to refuse certification or recertification as an HCO, the HCO or organization shall be entitled to a hearing before the administrative director or an administrative law judge which shall be shall be held in accordance with the Administrative Procedure Act {Chapter 5 (commencing with Section 11500), of Part 1 of Division 3 of Title 2 of the Government Code}, and the administrative director shall have all of the powers granted under that act.


Note: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.





s 9779.3. Obligations of Employer Covered by a Contract with a Health Care Organization.
(a) When an insurer or employers, a group of self-insured employers, or self-insured employers have contracted with a health care organization certified pursuant to Section 4600.5 of the Labor Code the employer shall provide information to all employees who are eligible to be enrolled in the health care organization as follows:
(1) a new employee shall be provided with the choice of enrolling in an HCO or designating the employee's own personal physician or personal chiropractor no later than 30 days following the employee's date of hire.
(2) a current employee shall be provided with the choice of enrolling in an HCO or designating the employee's own personal physician or personal chiropractor no later than 30 days before the initial enrollment period ends;
(3) an employer must provide information concerning the HCO it is offering to its employees no later than 30 days prior to the final date for enrollment. Information shall be provided in written form, in no less than twelve (12) point typeface, and in a language understandable to employees. The information provided must include, at a minimum, the following:
(i) the name of the HCO offered;
(ii) the corporate or business name of all entities which own or control the HCO offered; and indication of relationship, if any, of the HCO to workers' compensation carrier or self-insured employer;
(iii) the services offered by the HCO;

(iv) a complete listing of all primary treating physicians, specialist physicians, and clinics participating in the HCO who would be reasonably accessible to the employee for the provision of occupational health services. Primary treating physicians who are not accepting new patients must be clearly identified;
(v) If the HCO is also the provider of group health coverage for non-occupational health services, the HCO policy regarding enrollees' ability to use their personal physician (for non-occupational health services) for treatment of work injuries.
(vi) any provider risk-sharing arrangements related to utilization of services.
(4) Within fifteen days following enrollment, the HCO must provide to each enrollee complete information regarding HCO services and processes, including but not limited to:
(i) the services offered, including interpreters services, how such services are obtained, hours of services;
(ii) the definition of emergency care, how to obtain out-of-service treatment, how to obtain after-hours services;
(iii) case management and medical management processes, selection of the primary treating physician, and method for obtaining second opinions, change of physician, or referrals to chiropractors, physical therapists, or specialists;
(iv) the grievance and dispute resolution procedures;
(v) additional services offered, including return to work, health and safety, patient assistance, and patient education.
(b) Employees shall designate their enrollment option on form DWC 1194. This form must be maintained in the employee's personnel file for a minimum of three (3) years, and be made available to the employee or employee's representative on request.
Employees who designate on form DWC 1194 that they do not wish to enroll in an HCO and wish to pre-designate their own personal physician or personal chiropractor or personal acupuncturist shall pre-designate that personal physician or personal chiropractor or personal acupuncturist on the form 1194. At least once each year the employer shall provide the employee with a notice informing the employee of his or her right to continue as an enrollee of the HCO, change to another HCO if another HCO is offered by the employer, or designate the employee's own personal physician, personal chiropractor or personal acupuncturist instead of the HCO. If another HCO is offered by the employer and the employee chooses to change to another HCO, or if the employee chooses to designate a personal physician, personal chiropractor or personal acupuncturist, the employee shall designate such choice on a form DWC 1194, which shall be provided by the employer. (continued)