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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

§9767.16. Notice to Employee Upon Termination, Cessation of Use, or Change of Medical Provider Network

(a) The Medical Provider Network Applicant is responsible for ensuring that each injured covered employee is informed in writing of the MPN policies under which he or she is covered and when the injured employee is no longer covered by the Applicant's MPN. The MPN Applicant shall ensure each injured covered employee is given written notice of the date of termination or cessation of use of its MPN. The written notice shall be provided to injured covered employees prior to the effective date of termination or cessation of use of the Applicant's MPN. The notices required by this section shall be provided in English and also in Spanish to Spanish speaking employees.

(1) The MPN Applicant whose MPN is being terminated or will cease to be used shall ensure that every injured covered employee is provided the following information prior to the termination or cessation of use of its MPN by a MPN Applicant or an insured employer:

(A) The effective date of termination or cessation of use of the Applicant's MPN.

(B) Whether the MPN will still be used for injuries arising before the date MPN coverage ends.

(C) The address, telephone number, email address and an MPN website, (optional), of the MPN Contact who can address MPN questions.

(D) For periods when an employee is not covered by a MPN, an employee may choice a physician 30 days after the date the employee notified the employer of his or her injury.

(E)(2) The following language may be provided in writing to injured covered employees to give the required notice of termination or cessation of use of a MPN: “The <Insert MPN Name> Medical Provider Network (MPN) will no longer be used for injuries arising after <Insert Date of MPN Termination or Cessation of Use>. You will/will not <Select Whichever is Appropriate> continue to use this MPN to obtain care for work injuries occurring before this date. For new injuries that occur when you are not covered by a MPN, you have the right to choose your physician 30 days after you notify your employer of your injury. You may obtain more information at <Insert MPN Contact Phone Number, Address, Email Address, and MPN Website (optional).”

(3) The notice of MPN termination or cessation of use 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 end of MPN coverage. 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 end of MPN coverage.

(4) Any pending Independent Medical Review will end with the employee's coverage under the MPN.

(b) If a MPN Applicant or insured employer is changing MPN coverage to a different MPN, the MPN Applicant that is providing the new MPN coverage shall ensure that every injured covered employee is provided written notice of the following information prior to the effective date of coverage under that Applicant's MPN:

(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 covered under the prior MPN or may be transferred into the new MPN. The worker should check with the worker's claims adjuster for more information;

(4) That for periods when the worker is not covered by a MPN, an employee may choose a physician 30 days after the date the employee notified the employer of his or her injury;

(5) The MPN Contact's telephone number, address, email address, and an MPN website (optional), for the worker to obtain more information about using the MPN.

(c) The following language may be provided in writing to injured covered employees to give the required notice of the change of MPN coverage: “Unless you predesignate a physician or medical group prior to injury, 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 continue care under your prior MPN or you may be required to change to a provider in the new MPN. Check with your claims adjuster. For periods when you are not covered under a MPN, you may choose a physician 30 days after you've notified your employer of your injury. You may obtain more information at <INSERT MPN CONTACT, PHONE NUMBR, ADDRESS, EMAIL ADDRESS, AND AN MPN WEBSITE (optional).”

(d) Notice of termination or cessation of use of a MPN may be combined with the notice of a change to new MPN coverage if the combined notice meets all the MPN regulatory requirements for termination or cessation of use of a MPN and for change of a MPN.

(e) Notices required by this section shall be provided in English and also in Spanish to Spanish speaking employees.

(f) The notice of a change of MPN coverage may be provided by mail or included on or with an employee's paystub, paycheck or distributed through electronic means, including email, if the covered employee has regular electronic access to email at work to receive this notice prior to the beginning of new MPN coverage. 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 beginning of new MPN coverage.

(g) If a change in MPN coverage results in modifications to an MPN's plan application or results in the filing of a new MPN application, the MPN modification or new application filing shall be submitted to DWC pursuant to section 9767.8 or 9767.3, whichever is applicable. Distribution to injured covered employees of the notice of a change of MPNs shall occur after DWC's approval of a MPN modification or new MPN.

Note: Authority cited: Sections 59, 124, 133, 138.3, 138.4, 4616 and 5307.3, Labor Code. Reference: Sections 3550 and 4616.2, Labor Code.

HISTORY

1. New section filed 12-11-2007; operative 4-9-2008 (Register 2007, No. 50).

2. Amendment of section heading, section and Note filed 8-9-2010; operative 10-8-2010 (Register 2010, No. 33).

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