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

§9767.10. Continuity of Care Policy.

(a) At the request of a covered employee, an insurer, employer, or an entity that provides physician network services that offers a medical provider network shall complete the treatment by a terminated provider as set forth in Labor Code sections 4616.2(d) and (e).

(b) An “acute condition,” as referred to in Labor Code section 4616.2(d)(3)(A), shall have a duration of less than ninety days.

(c) “An extended period of time,” as referred to in Labor Code section 4616.2(d)(3)(B) with regard to a serious and chronic condition, means a duration of at least ninety days.

(d) The MPN applicant's continuity of care policy shall include a dispute resolution procedure that contains the following requirements:

(1) Following the employer's or insurer's determination of the injured covered employee's medical condition, the employer, insurer, or an entity that provides physician network services shall notify the covered employee of the determination regarding the completion of treatment and whether or not the employee will be required to select a new provider from within the MPN. The notification shall be sent to the covered employee's address and a copy of the letter shall be sent to the covered employee's primary treating physician. The notification shall be written in English and Spanish and use layperson's terms to the maximum extent possible.

(2) If the terminated provider agrees to continue treating the injured covered employee in accordance with Labor Code section 4616.2 and if the injured covered employee disputes the medical determination, the injured covered employee shall request a report from the covered employee's primary treating physician that addresses whether the covered employee falls within any of the conditions set forth in Labor Code section 4616.2(d)(3); an acute condition; a serious chronic condition; a terminal illness; or a performance of a surgery or other procedure that is authorized by the insurer or employer as part of a documented course of treatment and has been recommended and documented by the provider to occur within 180 days of the contract's termination date. The treating physician shall provide the report to the covered employee within twenty calendar days of the request. If the treating physician fails to issue the report, then the determination made by the employer or insurer referred to in (d)(1) shall apply.

(3) If the employer or insurer or injured covered employee objects to the medical determination by the treating physician, the dispute regarding the medical determination made by the treating physician concerning the continuity of care shall be resolved pursuant to Labor Code section 4062.

(4) If the treating physician agrees with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in Labor Code section 4616.2(d)(3), the employee shall choose a new provider from within the MPN during the dispute resolution process.

(5) If the treating physician does not agree with the employer's or insurer's determination that the injured covered employee's medical condition does not meet the conditions set forth in Labor Code section 4616.2(d)(3) , the injured covered employee shall continue to treat with the terminated provider until the dispute is resolved

Note: Authority cited: Sections 133 and 4616(h), Labor Code. Reference: Section 4616.2, Labor Code.

1. New 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 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 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, transmitted to OAL 7-29-2005 and filed 9-9-2005 (Register 2005, No. 36).

5. Amendment of subsections (a) and (d)(1) and amendment of Note filed 8-27-2014; operative 8-27-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 35)