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General information for applicants

A: A medical provider network (MPN) is a network of providers, including physicians, created to provide medical treatment for work injuries of employees in California. MPNs are created by payors (self-insured employers or workers' compensation insurers) and must be approved by the California Division of Workers' Compensation (DWC). Unless exempted by law or the employer, all medical care for workers injured on the job whose employer has an approved MPN will be handled and provided through the MPN. [8 CCR § 9767.1 et seq.]

Q: Where can I find the regulations pertaining to MPNs?

A: The MPN regulations are found in Title 8, California Code of Regulations, sections 9767.1 - 9767.15 (MPN regulations). The regulations are posted on the MPN page of the DWC Web site: http://www.dir.ca.gov/dwc/dwcpropregs/MPNReg.htm

Q: Are MPNs mandatory after Jan. 1, 2005?

A: No. A workers' compensation insurance carrier, self-insured employer, joint powers authority, the state of California, California Insurance Guarantee Association (CIGA), State Compensation Insurance Fund (SCIF), and a group of self insured employers may choose to create an MPN. There is no requirement to do so. Each eligible payor may decide for its own organization if it wants to establish and use an MPN for their employees' occupational medical care.

Q: Who is covered by an MPN?

A: All employees of an employer with an approved MPN are required to receive medical treatment through the MPN for work injuries, EXCEPT:

• Those employees who properly pre-designate a physician anytime before an injury occurs, even if the pre-designated physician is a provider in the MPN's network. [8 CCR §9780.1, 8 CCR §9782];
• Those employees with injuries prior to the effective date of the MPN whose care has not been transferred into the MPN [8 CCR §9767.9]; and
• Those employees who are otherwise exempted from the MPN by the MPN payor or employer.

Q: Who can apply for an MPN?

A: A workers' compensation insurer, self-insured employer, joint powers authority, the state of California, California Insurance Guarantee Association (CIGA), State Compensation Insurance Fund (SCIF), and groups of self insured employers.

Q: What if I am covered by a master certificate of consent to self insure?

A: Entities who are insured under a master certificate of consent to self insure may submit one MPN application under the name of the master certificate holder. The application should list each company under the master certificate applying for an MPN and each entity's tax ID number, including the master certificate holder's tax ID number. Although one application may be submitted for all entities insured under a master certificate, a cover page should still be submitted for each entity.

Q: Who cannot apply for an MPN?

A: Medical groups, PPO networks, insured employers, and third-party administrators cannot apply for an MPN.

Q: How do I apply for an MPN?

A: Submit an MPN application with the information required by the permanent MPN regulations, Title 8, California Code of Regulations, sections 9767.1 through 9767.15. The permanent MPN regulations are also on the DWC Web site: http://www.dir.ca.gov/dwc/dwcpropregs/MPNReg.htm

• Include a completed "MPN Cover Page for medical provider network application" with an original signature by the MPN applicant's authorized representative who must be an employee or officer in the applicant's organization. The cover page can be found on the DWC Web site: http://www.dir.ca.gov/dwc/dwcpropregs/MPNForm.pdf

Q: Where do I send my completed MPN application?

A: Submit the completed application by mail to:

CA Department of Industrial Relations
Division of Workers' Compensation
MPN Applications
P.O. Box 71010
Oakand, CA 94612

OR

by overnight delivery to:

CA Department of Industrial Relations
Division of Workers' Compensation
MPN Applications
1515 Clay St. 17th floor
Oakland, CA 94612

Q: Who is responsible for the MPN?

A: The MPN applicant is responsible for compliance with the MPN regulations, regardless of any delegated authority given to a third party to administer an MPN.

Q: Can we submit our MPN application electronically?

A: No. Currently, DWC is not accepting MPN applications, MPN updates, or material modifications electronically. All MPN submissions are to be sent in hard copy to the MPN address.

Q: Who must sign the MPN application?

A: An authorized officer or employee of the eligible MPN applicant must sign the mandatory MPN cover page, the DWC Form CCR §9767.4.

Q: I've seen more than one version of the mandatory cover page for the MPN application. Which one should I use?

A: Make sure you use the new cover page, DWC Form 8 CCR 9767.4, which is included in the permanent regulations. Do not use any earlier version of this form. The cover page can be found on the DWC Web site: http://www.dir.ca.gov/dwc/dwcpropregs/MPNForm.pdf

Q: What is the deadline for applying to be an MPN?

A: There is no deadline for applying for an MPN. MPN applications may be submitted to DWC on or after Nov. 1, 2004 and can continue to be submitted any time thereafter.

Q: What providers should be included in an MPN?

A: Licensed physicians and providers of medical services pursuant to Labor Code sections 3209.3 and 3209.5 are to be included in the MPN. These providers include physicians, surgeons, psychologists, acupuncturists, optometrists, dentists, chiropractic practitioners, acupuncturists, and physical therapists. All MPN providers must have a contractual agreement to treat workers' compensation injuries to be included in an MPN. The MPN provider network shall also include ancillary services as defined under Labor Code 3209.5.

Note: All medical providers defined by Labor Code sections 3209.3 and 3209.5 must comply with all relevant laws and regulations governing the practice of medicine in the State of California. For example, the services of non-professional radiology network corporations to perform any action reserved to licensed physicians may constitute the unlawful practice of medicine. For more information, see the attorney general's opinion no. 00-206, on non-professional radiology network corporations: http://ag.ca.gov/opinions/pdfs/00-206.pdf

Q: Can DWC add a provider to an MPN network?

A: No. The MPN applicants determine which providers will be in their provider networks.

Q: If I am a provider, how do I get added to a network?

A: As a provider, you need to contact payors (self-insured employers or workers' compensation insurers) to offer your services as a network provider. You can also contact organizations which contract with providers such as PPOs, HCOs, HMOs or other network entities.

NOTE: A memorandum for providers interested in joining an MPN network can be found at: http://www.dir.ca.gov/dwc/MPN/DWC_MPN_Main.html

Q: Must chiropractors and acupuncturists be included in our MPN network?

A: Yes. Under Labor Code section 3209.3 and section 3209.5, MPNs must include acupuncturists and chiropractors as providers.

Q: Can we submit our provider list on disk?

A: Yes, under the permanent regulations, you may submit your provider listing on disk or CD-ROM as a Microsoft Excel or Microsoft Access file together with the hard copy of your MPN application.

Q: We are planning to use a certified HCO as the deemed network for our MPN. Can we change some of the providers in the network and file our application under Title 8, California Code of Regulations § 9767.3 (e)?

A: If you are using an HCO as your MPN network, you must use the entire list of HCO providers as the HCO was certified and may not make any modification to the HCO provider list in order for your MPN application to be reviewed as an MPN using a deemed entity. If you make any changes to an HCO's provider listing, you are no longer filing as a "deemed entity", and must file under 8 CCR §9767.3 (d) including your entire provider listing as requested under 8 CCR §9767.3(d)(8)(C) and (D). If you have questions about using the network of a deemed entity, discuss these issues with that entity before submitting your MPN application.

NOTE: If the MPN applicant is providing ancillary services within the MPN in addition to the services provided by a deemed entity, the ancillary services shall be set forth in the application. [8 CCR §9767.3(g)].

The HCO regulations can be found at: http://www.dir.ca.gov/t8/ch4_5sb1a4.html

Q: Does DWC have a ratio of necessary physicians to the expected number of injury cases for an MPN?

A: No. There is no specific ratio of physicians to expected injuries. In order to establish that your MPN has a sufficient number and type of providers, here are some things you may want to consider:

• Number of employees to be covered;
  
• Geographic service area to be covered;
  
• Number and types of injuries expected;
  
• Number and types of providers needed to accommodate injured workers' right to change physicians, and to support the 2nd and 3rd opinion process;
  
• Number and type of providers needed to meet the MPN access standards for PTP, specialist and hospital access.

  NOTE: As of Sep. 15, 2005, a minimum of three physicians per specialty within the access standards must be available to employees. [8 CCR §9767.5(a)].

Q: What kind of MPN provider listing is required to be given to covered employees?

A: At a minimum, a written regional provider listing is to be provided to covered employees, as required by 8 CCR §9767.12 (a)(3) and as defined in 8 CCR §9767.1(a)(20). It is not acceptable to only provide a select list of five or 10 providers, as that does not constitute a complete regional provider listing. If the provider directory is available on a Web site, the URL shall be provided, as well as sufficient information to allow an employee to access the provider directory online. [8 CCR §9767.12 (a)(3)].

Q: If a worker or a worker's representative requests a complete provider listing in writing, must it be provided?

A: Yes. If a worker or a worker's representative requests a complete provider listing of all providers in the MPN, it is to be made available in writing. [8 CCR §9767.12(a)(3)].

Q: What can I do to increase my chances of getting my application approved more quickly?

A: Read and carefully follow the final MPN regulations, which became effective Sep. 15, 2005.

Before submitting your application to DWC, make sure that it is complete by double checking that it has all the required information, including

• A cover page signed by the applicant's authorized individual.
  
• The correct tax ID number ( for those entities who are under one master self-insured certificate, please state the tax ID number for the master self insured entity also);
  
• The number of covered employees for the MPN;
  
• An MPN liaison listed with the phone, mailing and email address.

Q: Is there any information that applicants often forget to include in their applications?

A: Yes. Remember to include the following information in your application:

• A description of any alternative rural access policy, if applicable [8 CCR §9767.5(d)];
  
• A written policy for covered employees working or living outside the MPN geographic service area who need non-emergency medical care [8 CCR §9767.5(e)];
  
• An MPN contact name and phone number [8 CCR §9767.12(a)(1)];
  
• Statements disclosing that a copy of the entire continuity of care policy (COC) and the transfer of care (TOC) policy are available upon request; [8 CCR §9767.12(a)(12)-(13)];
  
• A statement that the second and third opinion physicians' reports will be given to the employee and the treating physician within 20 days of the employee's appointment; or the receipt of results of any tests, whichever is later [8 CCR §9767.7(f)].

  NOTE: Also, under the permanent MPN regulations, a toll free number is to be included in the employee notification for employees to obtain MPN assistance if the MPN geographic service area covers more than one area code. [8 CCR §9767.12(a)(1)].

Q: Can I use a DWC-approved application as a model for my application?

A: Yes. If you are using an approved application as a model, please reference in the pending application's cover letter, the name and approval number of the approved application used as a model.

Q: Can I use as a model an MPN application approved under the emergency regulations?

A: No. As of Sep. 15, 2005, the permanent regulations are in effect. All MPN applications received after Sep. 15, 2005 must comply with the permanent regulations, which include substantive changes to the emergency regulations.

For more information about these changes, please check the DWC Web site: http://www.dir.ca.gov/dwc/MPN/DWC_MPN_Main.html

Q: What if my application is incomplete?

A: If your application is determined to be "incomplete," DWC will send you a letter identifying the area(s) in which the application is incomplete. It is then up to you, the MPN applicant, to submit materials to ensure that your application is complete.

Q: How do I find out the status of my application?

A: DWC does not give status updates on applications. However, after receipt of your initial application and determination that all required information has been submitted, you will receive a letter of completeness. The letter of completeness will also include the MPN log number, which will allow you and DWC to identify and track the application.

All complete applications are processed for full review and are reviewed in the order received. Within 60 days of DWC's receipt of a complete application, you will be sent a decision letter stating whether the application has been approved or disapproved.

NOTE: If an email address is provided for the MPN DWC liaison, the decision letter will be sent by email as well as U.S. mail.

Q: What are common deficiencies seen in MPN applications that can lead to disapproval?

A: Some common problems identified in MPN applications are:

The imposition of additional or different time frames not required by the regulations. For example, imposing deadlines not in the regulations to respond or object to transfer of care determinations by the MPN applicant;

• Having an insufficient number or type of providers to meet the access standards as required by 8 CCR §9767.5 and by 8 CCR §9767.7;
• The failure to include all information required in the employee notification under 8 CCR. §9767.12;
• Changes made to the transfer of care dispute resolution process that are not allowed by the regulations;
• The use of vague terminology that does not reflect the requirements under the regulations, such as referring to "a specified time frame," or "specified circumstances";
• Failure to clearly inform a worker of the 60-day deadline for a waiver of the second or third opinion as required by 8 CCR §9767.7;
• Inconsistency between the policies and letters in the application.

Q: How do I find out if my application is disapproved?

A: You will receive a disapproval letter identifying the deficiencies in your application.

Q: What do I do if my application is disapproved?

A: If your application is disapproved:

• You will receive a disapproval letter stating the deficiencies found in the application. Carefully review the letter detailing the deficiencies in the application, and revise the application accordingly.
• Follow the instructions in the disapproval letter to prepare your resubmission.
• Submit an original and a copy of the revised application. If the employee notification materials have been revised, submit a copy in English and in Spanish.
• Include a newly signed cover page.

Q: Do I have to include a newly signed cover page when I submit my revised application?

A: Yes. All revisions to an MPN application must be accompanied by a newly signed cover page. No application will be approved without a signed cover page by the applicant's authorized representative indicating that the applicant has read the revised application and verified the contents of the revised application as true and correct. Resubmitting the original signed cover page with the initial application will not suffice.

Q: How long does it take to get my revised and resubmitted application reviewed?

A: Although the 60-day review period restarts upon resubmission of an application, resubmitted applications are considered a priority for review and will be expedited to the extent possible.

Q: How can I find out what MPNs have been approved?

A: Once DWC approves an MPN, it will be posted on the DWC MPN Web page, which can be found at http://www.dir.ca.gov/dwc/MPN/DWC_MPN_Main.html

Q: What is the "MPN Plan Approval Number"?

A: Upon approval of your MPN plan, the DWC will assign an MPN plan approval number. Each number will be unique in corresponding to one MPN plan. So, if a carrier creates three MPNs each one would have its own independent MPN approval number.

After approval: Filing a notice of plan modification for an approved MPN

Q: If I have an approved MPN and I want to make changes to the MPN, what do I need to do?

A: For most changes, you will need to submit a Notice of MPN plan modification. Changes which require a material modification are listed in 8 CCR §9767.8, which include, but are not limited to, the following changes:

• A change of 10% or more in the number or specialty of providers in an MPN network;
  
• A change in 25% or more in the number of employees to be covered by an MPN;
  
• A material change in either the continuity of care or transfer of care policies;
  
• A change in the economic profiling policy, including instituting an economic profiling policy when the original application stated that economic profiling was not performed;
  
• A change in the name of the MPN;
  
• A change in the geographic service is of the MPN, within the state of California;
  
• A change in how the MPN complies with the access standards;
  
• A change in the DWC liaison person for the MPN (NOTE: this change must be reported to DWC within five business days of the change taking place)
  
• Other changes, which include the termination, withdrawal or cessation of an MPN.

You will need to fill out and submit the material modification form in 8 CCR §9767.8, and submit a statement with the proposed modifications, including a copy of any proposed modified policies or employee notification.
The material modification form can be found on the DWC Web site at: http://www.dir.ca.gov/dwc/forms/mpn%5Fmaterialmodification.pdf

Q: After I file the Notice of MPN plan modification, can I go ahead and implement the changes in the MPN?

A: No. Unless it is a change in the name of the MPN or a change of the DWC liaison, DWC must review and approve the proposed changes to the MPN plan before the changes can be implemented. DWC will review your notice of plan modification and issue a decision on the plan modification within 60 days of receipt of a complete plan modification submission. You may institute the changes to your plan only after DWC issues its approval, or after 60 days if DWC fails to issue a decision on the plan modification within that time frame.

Q: What do we need to do if our company has an approved MPN and we decide to change carriers, third-party administrators or MPN networks?

A: When changing partners involved in an MPN contractual arrangement it is critical that you plan ahead to avoid any unnecessary disruption of MPN coverage for your employees. Even with careful planning it is possible that there could be some interruption of MPN coverage when changing third-party administrators, MPN networks or insurance carriers if enough time is not allowed for plan modification review and approval. Consult with DWC's managed care program staff as early as possible for guidance on implementing such a change as smoothly as possible.

Q: What happens if I have an approved MPN through my insurance carrier and I decide to become self-insured for workers' compensation?

A: If your company becomes self-insured you will no longer be covered by your former carrier's MPN. Employees with old injuries which occurred while you were covered by the carrier's MPN will stay in that carrier's MPN. As a self-insured employer you will have to file a new application for an MPN of your own. Depending on the changes to your network and policies, you would either need to provide a totally new or updated employee notification to reflect the changes in the MPN now being offered to your employees. Please consult with DWC managed care staff as early as possible to determine what will happen and how best to make the change.

Q: What happens if I am a self-insured employer and I decide to change third-party administrators (TPAs)?

A: It depends on how the original MPN was structured. If the MPN design, provider contracts, polices and/or operations had been delegated to the TPA you are leaving, you may need to file a completely new MPN. In other situations, you may only need to file a notice of MPN plan modification. Please consult with DWC managed care staff as early as possible to determine what will happen and how best to make the change.

Q: What should I do if I have an approved MPN under one insurance carrier and want to switch to a different MPN under a different carrier?

A: Before changing carriers, you should talk to the new carrier about how to ensure that your employees' coverage gets transitioned to the new MPN. This will most likely involve a new employee notification using the new carrier's MPN employee notification materials. It is possible that you could have an interruption of MPN coverage unless this change in carriers is carefully planned well before the effective date of the new policy. Please consult with DWC managed care staff as early as possible to determine what will happen and how best to make the change.

April 2007