Answers to frequently asked questions about medical provider networks (MPNs)
Topics covered in this FAQ include:
Q: What is an MPN?
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. Self-insured employers or workers' compensation insurers may have an MPN. Under SB 863, an entity providing physician network services can also have an MPN. An MPN must be approved by the California Division of Workers' Compensation (DWC) before it can be used. 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.
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 - 9767.16 (MPN regulations).
Q: Are MPNs mandatory after Jan. 1, 2005?
A: No. There is no requirement for employers or payors to use an MPN to treat covered work injuries. Each eligible employer, insurer, or entity providing physician network services may decide if it wants to establish and use an MPN to treat employees' occupational medical care.
Q: Who is covered by an MPN?
A: All employees of an employer using an approved and implemented MPN are required to receive medical treatment through the MPN for work injuries, EXCEPT:
- Those employees who properly pre-designate a physician any time before an injury occurs, even if the pre-designated physician is a provider in the MPN's network;
- Those employees with injuries prior to the effective date of the MPN whose care has not been transferred into the MPN; and
- Those employees who are otherwise exempted from the MPN by the MPN insurer 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. Under SB863, an entity providing physician network services will also be eligible to apply for an MPN.
Q: How do I apply for an MPN?
A: Submit an MPN application with the information required by the current MPN regulations.
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.
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
P.O. Box 71010
Oakland, CA 94612
Or by overnight delivery to:
CA Department of Industrial Relations
Division of Workers' Compensation
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, including the MPN liaison.
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,.
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 which is included in the permanent regulations. Do not use any earlier version of this form.
Q: What is the deadline for applying to be an MPN?
A: There is no deadline for applying for an MPN.
Q: What providers should be included in an MPN?
A: Licensed physicians and providers of medical services are to be included in the MPN. These providers include physicians, surgeons, psychologists, acupuncturists, optometrists, dentists, podiatrists, chiropractic practitioners, 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.
Note: The Attorney General has issued an opinion that an entity or individual not licensed to practice medicine may not perform professional radiology services, either as part of a medical provider network or otherwise. For more information, see the Attorney General's Opinion No. 08-803 on the performance of professional radiology services by an entity or individual not licensed to practice medicine.
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 the MPN applicants to offer your services as a network provider. You can also contact organizations which contract with applicants to provide network providers such as PPOs, HCOs, HMOs or other network entities.
Note: A memorandum for providers interested in joining an MPN network is located on the DWC website.
Q: Should chiropractors and acupuncturists be included in our MPN network?
A: MPNs must include acupuncturists and chiropractors as providers if they are commonly used by the employees being treated.
Q: Must we submit our provider list on disk?
A: Yes, under the current regulations, you must submit your provider listing on disk or CD-ROM as a Microsoft Excel file with your MPN application.
Q: We are planning to use the provider network of a certified Health Care Organization (HCO) as the deemed network for our MPN. Can we change some of the providers in the HCO network?
A: If you are using an HCO network as a “deemed entity” MPN network, you must use the entire list of HCO providers exactly as certified under the HCO and you may not make any modification to the provider list. If you make any changes to an HCO's provider listing, you are no longer filing as a "deemed entity," and must file your entire provider. 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.
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 second and third opinion processes;
- Number and type of providers needed to meet the MPN access standards for PTP, specialist and hospital access.
However, a minimum of three primary treating physicians and three providers for each commonly used specialty within the access standards must be available to employees.
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. It is not acceptable to only provide a select list of five or ten providers, as that does not constitute a complete regional provider listing. If the provider directory is available on a website, the URL shall be provided, as well as sufficient information to allow an employee to access the provider directory online.
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.
Q: What can I do to increase my chances of getting my application approved more quickly?
A: Read and carefully follow the current MPN regulations.
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 legal name as verified or certified by the Office of Self Insurance Plans (OSIP) or the Department of Insurance (DOI);
- The correct tax ID number for the MPN applicant;
- The number of covered employees for the MPN;
- An MPN liaison listed with the phone, mailing and email address;
- Complete provider listings with only the three required columns of name, location and specialty included.
- Include a copy of the cover page and application materials.
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;
- A written policy for covered employees working or living outside the MPN geographic service area who need non-emergency medical care;
- An MPN contact name and phone number;
- Statements disclosing that a copy of the entire continuity of care policy (COC) and the transfer of care (TOC) policy are available upon request;
- 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.
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.
Q: Can I use as a model an MPN application approved under the emergency regulations?
A: No. As of Sept. 15, 2005, the permanent regulations are in effect. All MPN applications received after Sept. 15, 2005 must comply with the current regulations.
For more information about the latest regulatory changes, please check the DWC website.
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. No further action will be taken on an incomplete submission and the regulatory review deadline does not begin until the submission is deemed 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;
- The failure to include all information required in the employee notification;
- 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;
- Inconsistency between the same policies stated 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 MPN 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 webpage.
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 include, but are not limited to, the following:
- 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 change in employee notification materials;
- 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 or authorized individual (NOTE: either change must be reported to DWC within five business days of the change taking place)
You will need to fill out and submit the material modification form, and submit a copy of any proposed modified policies or employee notification.
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 of the DWC liaison or a change of the authorized individual, 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 afterDWC 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 (TPAs) 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 TPAs, MPN networks or insurance carriers if enough time is not allowed for plan modification review and approval. Consult with DWC's MPN 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 long as it is being used by that carrier. As a self-insured employer you will have to file a new application for an MPN of your own. After the new MPN is approved, you would need to provide a totally new or updated employee notification to reflect the changes in the new MPN now being offered to your employees. Please consult with DWC MPN staff as early as possible to determine what will happen and how best to make the change from one MPN to another.
Q: What happens if I am a self-insured employer and I decide to change TPAs?
A: It depends on how the original MPN was structured. If the MPN design, provider listings and contracts, notices and policies were created by the TPA you are leaving, you may need to file a completely new MPN with new TPA’s MPN information. In other situations, you may only need to file a notice of MPN plan modification. Please consult with DWC MPN staff as early as possible to determine what will happen and how best to make the change to reduce the impact on covered injured workers.
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 MPN staff as early as possible to determine what will happen and how best to make the change.
A: Yes. The change of MPN notice is still required to be given to injured covered employees before an insured employer or an MPN applicant changes to another MPN within 60 days.
Q: When do we give out the implementation notice?
A: The MPN Implementation Notice must be given to every employee prior to the implementation of an approved MPN and must be provided to a new employee at the time of hire. Also, if more than 60 days has passed since an MPN was last used for the employer, an implementation notice must be sent to all covered employees, in addition to the termination/cessation of use of MPN notice for injured covered employees.
Q: If we are using an MPN that was approved before Oct. 8, 2010, can we still use our old employee notices?
A: If the old employee notices are in compliance with the revised regulations, then you can still use your old notices. If the old notices do not comply with the revised regulations, then new notices will need to be distributed. Please note: If an MPN plan application approved prior to Oct. 8 needs to be modified to comply with the latest regulations, a material modification filing may be required under the revised section 9767.8.
Q: What employee notices will need to be filed with DWC for new MPN applications on or after Oct. 8, 2010?
A: MPN applicants should submit (1) the complete MPN employee notification given at time of injury and transfer into the MPN and (2) the independent medical review (IMR) notices for review with their MPN applications, as is currently required. DWC requires the filing of the employee notification in 9767.12(d) and the IMR notice in 9767.12(g) with all MPN applications received on or after Oct. 8, 2010.
Q: Is there a grandfather clause, as there was for the 2005 permanent regulations, that allows us to update to the October 8 revised regulations only when we file a modification after the regulations go into effect?
A: No. All MPNs are expected to be in compliance with all the requirements of the new regulations on and after Oct. 8, 2010. All employee notices distributed on or after Oct. 8, 2010 will need to comply with the new regulations, irrespective of when the MPN was approved.
Q: If the MPN was approved prior to Oct. 8, 2010, do we still need to post the MPN employee notification?
A: Yes. The revised workers’ compensation poster states that if the employer is using an MPN, the complete employee notification will be posted.
Q: What do I do if I have questions about the new employee hire pamphlet, the claim form, or the workers’ compensation poster?
- Contact an Information and Assistance (I&A) officer at your nearest DWC district office.
Q: What significant changes affecting MPNs were made in SB863?
A: Significant changes affecting MPNs in SB 863 include the following:
An entity that provides physician network services can now also apply to be an MPN applicant.
For established MPNs:
- As of January 1, 2013, a contracting agent must inform MPN providers entering or renewing a provider contract that they are part of an MPN whether their contract is sold, leased, transferred or conveyed to another MPN applicant, contracting agent or WC insurer.
- Medical Access Assistants are required for each MPN to assist workers with finding available MPN physicians and contact physician offices for appointments, and must be available from 7 am-8 pm Pacific Standard Time from Monday through Saturday through a toll-free number.
- 4-Year Approval: MPN plans will be approved for four years, as of Jan. 1, 2014.
- Applications for re-approval of existing plans must be submitted six months prior to four-year approval expiration
- Geocoding of provider listings is required for re-approval
- Quality Assurance processes must be established for MPNs
- MPN physicians need to acknowledge that they elect to be part of the MPN, as of January 1, 2014.
- Each MPN will need to have a website and access to their provider listing on their website as of January 1, 2014:
- The provider listing must be updated quarterly
- The Administrative Director will post website addresses for approved MPNs
- The Administrative Director can conduct random audits and investigations of MPNs.
- The Administrative Director can impose penalties, probation, suspension or revocation with the right to appeal to the WCAB Reconsideration Unit.
- Any person contending that a MPN is not validly constituted may petition the Administrative Director to suspend or revoke the approval of an MPN.