Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 3.5. Medical Provider Networks

§9767.1. Medical Provider Networks -- Definitions.

(a) As used in this article:

(1) “Ancillary services” means any provision of medical services or goods as allowed in Labor Code section 4600 by a non-physician, including, but not limited to, interpreter services, physical therapy and pharmaceutical services.

(2) “Covered employee” means an employee or former employee whose employer has ongoing workers' compensation obligations and whose employer or employer's insurer is using a Medical Provider Network for the provision of medical treatment to injured employees unless:

(A) the injured employee has properly designated a personal physician pursuant to Labor Code section 4600(d) by notice to the employer prior to the date of injury, or;

(B) the injured employee's employment with the employer is covered by an agreement providing medical treatment for the injured employee and the agreement is validly established under Labor Code section 3201.5, 3201.7 or 3201.81.

(3) “Division” means the Division of Workers' Compensation.

(4) “Economic profiling” means any evaluation of a particular physician, provider, medical group, or individual practice association based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, medical group, or individual practice association.

(5) “Emergency health care services” means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy.

(6) “Employer” means a self-insured employer, the Self-Insurer's Security Fund, a group of self-insured employers pursuant to Labor Code section 3700(b) and as defined by Title 8, California Code of Regulations, section 15201(s), a joint powers authority, or the state.

(7) “Entity that provides physician network services” means a legal entity employing or contracting with physicians and other medical providers or contracting with physician networks, and may include but is not limited to third party administrators and managed care entities, to deliver medical treatment to injured workers on behalf of one or more insurers, self-insured employers, the Uninsured Employers Benefits Trust Fund, the California Insurance Guaranty Association, or the Self-Insurers Security Fund, and that meets the requirements of this article, Labor Code 4616 et seq., and corresponding regulations.

(8) “Geocoding” means the mapping of addresses within specific geographic location(s) or coordinate space.

(9) “Group Disability Insurance Policy” means an entity designated pursuant to Labor Code section 4616.7(c).

(10) “Health Care Organization” means an entity designated pursuant to Labor Code section 4616.7(a).

(11) “Health Care Service Plan” means an entity designated pursuant to Labor Code section 4616.7(b).

(12) “Health care shortage” means a situation in a geographical area in which the number of physicians in a particular specialty who are available and willing to treat injured workers under the California workers' compensation system is insufficient to meet the Medical Provider Network access standards set forth in 9767.5(a) through (c) to ensure medical treatment is available and accessible at reasonable times. A lack of physicians participating in an MPN does not constitute a health care shortage where a sufficient number of physicians in that specialty are available within the access standards and willing to treat injured workers under the California workers' compensation system.

(13) “Insurer” means an insurer admitted to transact workers' compensation insurance in the state of California, California Insurance Guarantee Association, or the State Compensation Insurance Fund.

(14) “Medical Provider Network” ( “MPN”) means any entity or group of providers approved as a Medical Provider Network by the Administrative Director pursuant to Labor Code sections 4616 to 4616.7 and this article.

(15) “Medical Provider Network Identification Number” means the unique number assigned by DWC to a Medical Provider Network upon approval or within ninety (90) days of the effective date of these regulations and used to identify each approved Medical Provider Network.

(16) “Medical Provider Network Medical Access Assistant” means an individual in the United States provided by the Medical Provider Network to help injured workers with finding available Medical Provider Network physicians of the injured workers' choice and with scheduling provider appointments.

(17) “Medical Provider Network Geographic Service Area” means the geographic area within California in which medical services will be provided by the Medical Provider Network.

(18) “Medical Provider Network Plan” means an employer's, insurer's, or entity that provides physician network services' detailed description for a Medical Provider Network contained in a complete application submitted according to the the requirements of this article to the Administrative Director by an MPN Applicant.

(19) “MPN Applicant” means an insurer or employer or an entity that provides physician network services as defined in this section who is legally responsible for the Medical Provider Network.

(20) “MPN Contact” means an individual(s) designated by the MPN Applicant in the employee notification who is responsible for responding to complaints, for answering employees' questions about the Medical Provider Network and for assisting the employee in arranging for an MPN independent medical review pursuant to Labor Code section 4616.4.

(21) “Occupational Medicine” means the diagnosis or treatment of any injury or disease arising out of and in the course of employment.

(22) “Primary treating physician” means a primary treating physician within the medical provider network and as defined by section 9785(a)(1).

(23) “Probation” means a Medical Provider Network's approval is conditioned on the completion of specified actions within a stated time frame as required by the Administrative Director for the Medical Provider Network to comply with the requirements of this article and Labor Code sections 4616 et seq.

(24) “Provider” means a physician as described in Labor Code section 3209.3 or other practitioner as described in Labor Code section 3209.5.

(25) “Regional area listing” means either:

(A) a listing of all MPN providers within a 15-mile radius of an employee's worksite or residence; or

(B) a listing of all MPN providers in the county where the employee resides or works if

1. the employer or insurer cannot produce a provider listing based on a mile radius

2. or by choice of the employer or insurer, or upon request of the employee.

(C) If the listing described in either (A) or (B) does not provide a minimum of three physicians of each specialty, then the listing shall be expanded by adjacent counties or by 5-mile increments until the minimum number of physicians per specialty are met.

(26) “Residence” means the covered employee's primary residence.

(27) “Revocation” means the permanent termination of a Medical Provider Network's approval.

(28) “Second Opinion” means an opinion rendered by a medical provider network physician after an in person examination to address an employee's dispute over either the diagnosis or the treatment prescribed by the treating physician, pursuant to Labor Code section 4616.3.

(29) “Suspension” means the temporary discontinuance of MPN coverage for new claims within a specified period as required by the Administrative Director.

(30) “Taft-Hartley health and welfare fund” means an entity designated pursuant to Labor Code section 4616.7(d).

(31) “Termination” means the permanent discontinued use of an implemented MPN that ceases to do business.

(32) “Third Opinion” means an opinion rendered by a medical provider network physician after an in person examination to address an employee's dispute over either the diagnosis or the treatment prescribed by either the treating physician or physician rendering the second opinion, pursuant to Labor Code section 4616.3.

(33) “Treating physician” means any physician within the MPN applicant's medical provider network other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.

(34) “Withdrawal” means the permanent discontinuance of an approved MPN that was never implemented.

(35) “Workplace” means the geographic location where the covered employee is regularly employed.

Note: Authority cited: Sections 133 and 4616(h), Labor Code. Reference: Sections 1063.1, 3208, 3209.3, 3209.5, 3700, 3702, 3743, 4616, 4616.1, 4616.3, 4616.5 and 4616.7, Labor Code; and California Insurance Guarantee Association v. Division of Workers' Compensation (April 26, 2005) WCAB No. Misc. #249.

HISTORY

1. New article 3.5 (sections 9767.1-9767.14) and section filed 11-1-2004 as an emergency; operative 11-1-2004 (Register 2004, No. 45). A Certificate of Compliance must be transmitted to OAL by 3-1-2005 or emergency language will be repealed by operation of law on the following day.

2. New article 3.5 (sections 9767.1-9767.14) and section refiled 2-28-2005 as an emergency; operative 3-1-2005 (Register 2005, No. 9). A Certificate of Compliance must be transmitted to OAL by 6-29-2005 or emergency language will be repealed by operation of law on the following day.

3. New article 3.5 (sections 9767.1-9767.14) and section refiled 6-20-2005 as an emergency; operative 6-29-2005 (Register 2005, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 6-20-2005 order, including amendment of section and Note, transmitted to OAL 7-29-2005 and filed 9-9-2005 (Register 2005, No. 36).

5. New subsections (a)(2) and (a)(25), subsection renumbering and amendment of newly designated subsection (a)(14) filed 12-11-2007; operative 4-9-2008 (Register 2007, No. 50).

6. Amendment of section and Note filed 8-27-2014; operative 8-27-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 35).