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

New query

§9767.12. Employee Notification

(a) An employer or insurer that offers a Medical Provider Network Plan under this article shall notify every covered employee in writing about the use of the Medical Provider Network prior to the implementation of an approved MPN. An implementation notice shall also be provided to a new employee at the time of hire. An implementation notice is not required if the MPN Applicant or insured employer is changing from one MPN to another MPN within 60 days. The MPN implementation notice shall be provided in English and also in Spanish, to Spanish-speaking employees. The written MPN implementation notice to all covered employees shall, at a minimum, include the following information:

(1) That medical treatment for new work injuries will be provided through the Medical Provider Network as of the effective date of coverage unless the employee properly predesignates a physician or medical group prior to injury;

(2) The effective date of coverage under the new MPN;

(3) That existing work injuries may be transferred into the new MPN. The worker should check with the worker's claims adjuster for more information;

(4) That more information about the MPN can be found on the workers' compensation poster or by asking your employer.

(b) The following language may be used for the written MPN implementation notice provided to covered employees: “Unless you predesignate a physician or medical group, your new work injuries arising on or after <INSERT EFFECTIVE DATE OF NEW MPN> will be treated by providers in a new Medical Provider Network, <INSERT NEW MPN NAME>. If you have an existing injury, you may be required to change to a provider in the new MPN. Check with your claims adjuster. You may obtain more information about the MPN from the workers'compensation poster or from your employer.”

(c) The MPN implementation notice may be provided by mail or included on or with an employee's paystub, paycheck or distributed through electronic means, including email, if the employee has regular electronic access to email at work to receive this notice prior to the implementation of the MPN. If the employee cannot receive this notice electronically at work within the required time frame, then the employer shall ensure this information is provided to the employee in writing prior to the implementation of the MPN.

(d) Separate from the MPN implementation notice, a complete written MPN employee notification with the information specified in subdivision (f) of this section about coverage under the MPN shall be provided to covered employees at the time of injury or when an employee with an existing injury begins treatment under the MPN. This MPN notification shall be provided to employees in English and also in Spanish to Spanish speaking employees. Before MPN coverage is implemented, the complete written MPN employee notification shall also be posted in both English and Spanish in a conspicuous location frequented by employees during the hours of the workday and in close proximity to the workers' compensation posting required under section 9881.

(e) The complete MPN notification may be distributed through electronic means, including email, if the covered employee has regular electronic access to email at work to receive this notice at the time of injury or when the employee is being transferred into the MPN. If the employee cannot receive this notice electronically at work, then the employer shall ensure this information is provided to the employee in writing at the time of injury or when the employee is being transferred into the MPN.

(f) The complete written MPN employee notification shall include the following information:

(1) How to contact the person designated by the employer or insurer to be the MPN Contact for covered employees to answer questions about MPNs and to address MPN problems. The employer or insurer shall provide a toll-free telephone number with access to the MPN Contact if the MPN geographical service area includes more than one area code;

(2) A description of MPN services;

(3) How to review, receive or access the MPN provider directory. An employer or insurer shall ensure covered employees have access to, at minimum, a regional area listing of MPN providers in addition to maintaining and making available its complete provider listing in writing. If an employee requests an electronic listing, it shall be provided electronically on a CD or on a website. If the provider directory is also accessible on a website, the URL address shall be listed with any additional information needed to access the directory online. All provider listings shall be regularly updated, at minimum, on a quarterly basis with the date of the last update provided on the listing given to the employee, to ensure the listing is kept accurate. Each provider listing shall include a phone number and an email address for reporting of provider listing inaccuracies. If a listed provider becomes deceased or is no longer treating workers' compensation patients at the listed address the provider shall be taken off the provider list within 60 days of notice to the MPN network administrator.

(4) How to access initial care and subsequent medical care;

(5) The mileage, time requirements and alternative access standards required under section 9767.5;

(6) How to access treatment if (A) the employee is authorized by the employer to temporarily work or travel for work outside the MPN's geographical service area; (B) a former employee whose employer has ongoing workers' compensation obligations permanently resides outside the MPN geographical service area; and (C) an injured employee decides to temporarily reside outside the MPN geographic service area during recovery;

(7) How to choose a physician within the MPN;

(8) What to do if a covered employee has trouble getting an appointment with a provider within the MPN;

(9) How to change a physician within the MPN;

(10) How to obtain a referral to a specialist within the MPN or outside the MPN, if needed;

(11) How to use the second and third opinion process;

(12) How to request and receive an independent medical review;

(13) A description of the standards for the transfer of care policy and a notification that a copy of the policy shall be provided to an employee upon request; and

(14) A description of the standards for the continuity of care policy and a notification that a copy of the policy shall be provided to an employee upon request.

(g) At the time of the selection of the physician for a third opinion, the covered employee shall be notified about the Independent Medical Review process. The notification shall be written in English and also in Spanish to Spanish speaking employees.

Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616, 4616.2 and 4616.3, Labor Code.

HISTORY

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 filed 8-9-2010; operative 10-8-2010 (Register 2010, No. 33).

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