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

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§9767.3. Application for a Medical Provider Network Plan.

(a) As long as the application for a medical provider network plan meets the requirements of Labor Code section 4616 et seq. and this article, nothing in this section precludes an employer or insurer from submitting for approval one or more medical provider network plans in its application.

(b) Nothing in this section precludes an insurer and an insured employer from agreeing to submit for approval a medical provider network plan which meets the specific needs of an insured employer considering the experience of the insured employer, the common injuries experienced by the insured employer, the type of occupation and industry in which the insured employer is engaged and the geographic area where the employees are employed.

(c) All MPN applicants shall submit an original Cover Page for Medical Provider Network Application with original signature, an original application, and a copy of the Cover Page for Medical Provider Network and application to the Division.

(1) A MPN applicant shall submit the provider information and/or ancillary service provider information required in section 9767.3(d)(8)(C) and (D) on a computer disk(s) or CD ROM(s). The information shall be submitted as a Microsoft Excel spread sheet unless an alternative format is approved by the Administrative Director.

(2) If the network provider information is submitted on a disk(s) or CD ROM(s), the provider file must have only the following three columns. These columns shall be: (1) physician name (2) specialty and (3) location of each physician. By submission of its provider listing, the Applicant is affirming that all of the physicians listed have a valid and current license number to practice in the State of California.

(3) The ancillary service provider file must have only the following three columns. The columns shall be (1) the name of the each ancillary provider (2) specialty or type of service and (3) location of each ancillary service provider. By submission of an ancillary provider listing, the Applicant is affirming that the providers listed have a current valid license number to practice, if they are required to have a license by the State of California.

(d) If the network is not a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, a Medical Provider Network application shall include all of the following information:

(1) Type of MPN Applicant: Insurer or Employer.

(2) Name of MPN Applicant.

(3) MPN Applicant's Taxpayer Identification Number.

(4) Name of Medical Provider Network, if applicable.

(5) Division Liaison: Provide the name, title, address, e-mail address, and telephone number of the person designated as the liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the MPN.

(6) The application must be verified by an officer or employee of the MPN applicant with the authority to act on behalf of the MPN applicant with respect to the MPN. The verification by the authorized individual shall state: “I, the undersigned officer or employee of the MPN applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this application is true and correct.”

(7) Nothing in this section precludes a network, entity, administrator, or other third-party, upon agreement with a MPN applicant, from preparing a MPN application on behalf of an insurer or employer.

(8) Description of Medical Provider Network Plan:

(A) State the number of employees expected to be covered by the MPN plan;

(B) Describe the geographic service area or areas within the State of California to be served;

(C) The name, specialty, and location of each physician as described in Labor Code Section 3209.3, or other providers as described in Labor Code Section 3209.5, who will be providing occupational medicine services under the plan. By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the physicians, providers or medical group practice in the MPN to provide treatment for injured workers in the workers' compensation system and that the contractual agreement is in compliance with Labor Code section 4609, if applicable.

(D) The name, specialty or type of service and location of each ancillary service, other than a physician or provider covered under subdivision (d)(8)(C) of this section, who will be providing medical services within the medical provider network. By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the ancillary service providers to provide services to be used under the MPN;

(E) Describe how the MPN complies with the second and third opinion process set forth in section 9767.7;

(F) Describe how the MPN complies with the goal of at least 25% of physicians (not including pediatricians, OB/GYNs, or other specialties not likely to routinely provide care for common injuries and illnesses expected to be encountered in the MPN) primarily engaged in the treatment of nonoccupational injuries;

(G) Describe how the MPN arranges for providing ancillary services to its covered employees. Set forth which ancillary services, if any, will be within the MPN. For ancillary services not within the MPN, affirm that referrals will be made to services outside the MPN;

(H) Describe how the MPN complies with the access standards set forth in section 9767.5 for all covered employees;

(I) Describe the employee notification process, and attach an English and Spanish sample of the employee notification material described in sections 9767.12(d) and (g). Any specific MPN contact or provider listing access information that is not available for administrative review in the sample employee notification shall be included in the MPN employee notification distributed to employees;

(J) Attach a copy of the written continuity of care policy as described in Labor Code section 4616.2;

(K) Attach a copy of the written transfer of care policy that complies with section 9767.9;

(L) Attach any policy or procedure that is used by the MPN applicant or an entity contracted with the MPN or MPN applicant to conduct “economic profiling of MPN providers” pursuant to Labor Code section 4616.1 and affirm that a copy of the policy or procedure has been provided to the MPN providers or attach a statement that the MPN applicant does not conduct economic profiling of MPN providers;

(M) Provide an affirmation that the physician compensation is not structured in order to achieve the goal of reducing, delaying, or denying medical treatment or restricting access to medical treatment; and

(N) Describe how the MPN applicant will ensure that no person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, when these services are within the scope of the physician's practice, will modify, delay, or deny requests for authorization of medical treatment.

(e) If the entity is a Health Care Organization, a Medical Provider Network application shall set forth the following:

(1) Type of MPN Applicant: Insurer or Employer

(2) Name of MPN Applicant

(3) MPN Applicant's Taxpayer Identification Number

(4) Name of Medical Provider Network, if applicable.

(5) Division Liaison: Provide the name, title, address, e-mail address, and telephone number of the person designated as the liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the MPN.

(6) The application must be verified by an officer or employee of the MPN applicant with the authority to act on behalf of the MPN applicant with respect to the MPN. The verification by the authorized individual shall state: “I, the undersigned officer or employee of the MPN applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this application is true and correct.”

(7) Nothing in this section precludes a network, entity, administrator, or other third-party, upon agreement with a MPN applicant, from preparing a MPN application on behalf of an insurer or employer.

(8) Describe how the MPN complies with the second and third opinion process set forth in section 9767.7;

(9) Confirm that the application shall set forth that at least 25% of the network physicians are primarily engaged in nonoccupational medicine;

(10) Describe the geographic service area or areas within the State of California to be served and affirm that this access plan complies with the access standards set forth in section 9767.5;

(11) Describe the employee notification process, and attach an English and Spanish sample of the employee notification material described in sections 9767.12(d) and (g). Any specific MPN contact or provider listing access information that is not available for administrative review in the sample employee notification shall be included in the MPN employee notification distributed to employees;

(12) Attach a copy of the written continuity of care policy as described in Labor Code section 4616.2;

(13) Attach a copy of the written transfer of care policy that complies with section 9767.9 with regard to the transfer of on-going cases from the HCO to the MPN;

(14) Attach a copy of the policy or procedure that is used by the MPN applicant or an entity contracted with the MPN or MPN applicant to conduct “economic profiling of MPN providers” pursuant to Labor Code section 4616.1 and affirm that a copy of the policy or procedure has been provided to the MPN providers or attach a statement that the MPN applicant does not conduct economic profiling of MPN providers; and

(15) Describe the number of employees expected to be covered by the MPN plan and confirm that the number of employees is within the approved capacity of the HCO.

(16) By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the physicians, providers or medical group practice in the MPN to provide treatment for injured workers in the workers' compensation system and that the contractual agreement with the providers is in compliance with Labor Code section 4609, if applicable.

(f) If the entity is a Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, in addition to the requirements set forth in subdivision (e) [excluding (e)(9) and (e)(15)] of this section, a Medical Provider Network application shall include the following information:

(1) The application shall set forth that the entity has a reasonable number of providers with competency in occupational medicine.

(A) The MPN applicant may show that a physician has competency by confirming that the physician either is Board Certified or was residency trained in that specialty.

(B) If (A) is not applicable, describe any other relevant procedure or process that assures that providers of medical treatment are competent to provide treatment for occupational injuries and illnesses.

(g) If the MPN applicant is providing for ancillary services within the MPN that are in addition to the services provided by the Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, it shall set forth the ancillary services in the application.

(h) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been approved as a MPN, and the entity does not maintain its certification or licensure or regulated status, then the entity must file a new Medical Provider Network Application pursuant to section 9767.3(d).

(i) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been modified from its certification or licensure or regulated status, the application shall comply with subdivision (d) of this section.

Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 3209.3, 4609, 4616, 4616.1, 4616.2, 4616.3, 4616.5 and 4616.7, 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 and Note, transmitted to OAL 7-29-2005 and filed 9-9-2005 (Register 2005, No. 36).

5. Amendment of subsections (c)(1)-(3), (d)(6)-(7), (d)(8)(C)-(D), (d)(8)(I), (d)(8)(L), (e)(6)-(7), (e)(11), (e)(14), (f) and (i) filed 8-9-2010; operative 10-8-2010 (Register 2010, No. 33).

6. Change without regulatory effect amending subsections (c)(1), (d)(8)(I) and (e)(11) filed 9-23-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 39).

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