(a) The Administrative Director may conduct random reviews of any approved Medical Provider Network to determine if the requirements of this article and Labor Code sections 4616 through 4616.7 are being satisfied.
(1) An MPN will not be randomly reviewed more than once in a two-year period. However, an MPN may be subject to investigation for good cause.
(2) To initiate a random review, the Division of Workers' Compensation shall:
(A) Issue a “Notice of Random Review” to a Medical Provider Network's authorized individual specifying the parameters of the review, including the time frame and scope of the review.
(B) Make reasonable requests in writing for information or documentary evidence from the MPN in order to conduct the review. MPN applicants shall be prepared to respond to reasonable requests for information or documentary evidence by the DWC including, but not limited to, the following items:
(i) Documentary proof the MPN applicant meets the eligibility requirements to have an MPN, that the MPN name or MPN applicant name is legally correct and consistent with the approved MPN plan, or that the MPN status is still valid and approved.
(ii) A complete copy of the MPN's most recent approved plan submission (new MPN application, reapproval plan or modification) including a copy of the most recent employee notification and MPN notices given to covered employees, and a listing of all plan filings to date after the effective date of this section.
(iii) A copy of the most recent network provider listing, the URL address of the MPN's network provider listing, documentary evidence of quarterly updates to the provider listing for the past year and documentary evidence of timely corrections to the provider listing for inaccuracies reported to the MPN within a reasonable time period.
(iv) A copy of any MPN complaints or petitions for suspension or revocation received by the MPN and the MPN's responses. In addition, documentation of any administrative actions taken by the Administrative Director against the MPN within a reasonable time period may be requested.
(v) A copy of the telephone call logs tracking the calls and the contents of the calls made to and by the MPN medical access assistants and the MPN Contact within a reasonable time period.
(vi) Copies of the written MPN physician acknowledgments.
(3) The MPN applicant shall have thirty (30) calendar days from receipt of the Administrative Director's request, as determined by the parameters set forth in 9767.16(a)(2)(A) through (C), to provide DWC with the requested information and or documentary evidence.
(4) If the review reveals that the MPN has violated or is in violation of a provision of this article or of Labor Code sections 4616 through 4616.7, the Administrative Director shall notify the MPN applicant in writing of the specific violation(s) found and may follow the procedures set forth in section 9767.14 and/or section 9767.19.
Note: Authority cited: Sections 122 and 4616(h), Labor Code. Reference: Sections 4616(b)(4) and 4616(b)(5), Labor Code.
1. New section filed 8-27-2014; operative 8-27-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 35).